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RD33  B76  1 907       Five  hundred  surgica 


RECAP 


\¥/,i;rER  M.  BRICKNER,  M.D. 
I'lJ.  MOSCHCOWITZ,  M.  D. 


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500 
SURGICAL  SUGGESTIONS 


500 
SURGICAL  SUGGESTIONS 

PRACTICAL  BREVITIES 
IN   DIAGNOSIS  AND   TREATMENT 

BY 

WALTER  M.  BRICKNER,  B.S.,  M.  D. 

Chief  of  Surgical  Department,   Mount  Sinai  Hospital  Dispensary  ; 

Editor-in-Chief,  American  Journal  of  Surgery^ 

New    York, 


ELI  MOSCHCOWITZ,  A.  B.,  M.  D. 

Assistant  Physician^  Mount  Sinai  Hospital  Dispensary ; 

Associate  Editor^  American  Journal  of  Surgery, 

Nezv    York. 

SECOND  SERIES 


new  york,  u.  s.  a. 

Surgery  PubIvIShing  Company 

92  wii,i.iam  street 

1907 


\JJ  Ji,i^-^XJL^^  uMi-^Oi^vU 


<ion 


Copyright,  1907 

BY 

Surgery  Publishing  Company 


PREFACE 


The  first  issue  of  "  Surgical  Suggestions,"  published 
in  1906,  was  exhausted  in  a  few  months.  The  con- 
tinued demand  for  the  little  book  has  led  us  to  pre- 
pare this  second  series.  In  it  we  have  incorporated 
with  the  "Suggestions"  that  were  in  the  first  edition,  as 
many  more,  making  the  total  number  about  five  hundred. 

These  practical  brevities  make  no  pretensions  to 
completeness.  They  are  merely  observations  taken  here 
and  there  from  our  own  surgical  experiences. 

W.  M.  B. 
E.  M. 


August,  1907 


HEAD. 


SURGICAL  SUGGESTIONS. 

In  determining  whether  or  not  to  operate     Cranium. 
after  injuries  to  the  head,   a  surgical  judg- 
ment of  the  case  is  usually  better  than  one 
based   strictly  on  the  application   of   neuro- 
logical rules. 

There  is  no  class  of  cases  in  which  a  prog- 
nosis is  so  often  at  variance  with  the  extent 
of  the  injury  as  in  cranial  injuries.  The 
prognosis  in  such  cases  should,  therefore,  al- 
ways be  guarded. 

In  cases  of  head  traumata,  bleeding  from 
the  mouth  or  nose  does  not  necessarily  mean 
that  the  case  is  one  of  fracture  at  the  base. 
The  hemorrhage  may  be  entirely  due  to  a 
localized  injury. 

In  fractures  of  the  base  of  the  skull  with 
bleeding  from  the  ear  it  is  necessary  to  keep 
the  auditory  canal  absolutely  clean  in  order 
to  prevent  infection  of  the  meninges. 

"Egg  shell  crackle"  elicited  in  palpating 
a  tumor  of  the  cranial  bones  is  diagnostic  of 
sarcoma  originating  in  the  diploe. 


MEAD. 


Brain. 


Car. 


Depilatories  are  useful  in  the  preparation 
of  the  scalp  for  the  treatment  of  abscesses 
or  infected  wounds,  when  the  nature  of  the 
infection  or  the  matted  condition  of  the  hair 
makes  shaving  difficult. 

Tumors  of  the  brain  frequently  simulate, 
in  their  earlier  stages,  diseases  of  the  stomach. 

Lumbar  puncture  must  not  be  performed 
in  cases  of  tumor  of  the  brain.  Sudden  death 
has  frequently  happened  in  such  cases. 

In  exploring  for  tumors  of  the  brain,  the 
best  guide  for  determining  an  isolated  hard- 
ness is  the  finger;  the  use  of  a  needle  is  very 
deceptive. 

A  furuncle  deeply  situated  in  the  external 
auditory  canal  gives  signs  that  may  be  mis- 
taken for  mastoiditis.  Great  pain  when  the 
concha  is  moved  about,  will  serve  to  differ- 
entiate it  from  the  latter. 

Severe  and  repeated  headaches  may  be 
due  to  the  unsuspected  presence  of  otitis 
media,  with  or  without  mastoiditis. 


8 


HEAD. 


In  cases  of  unaccountable  fever,  especially 
in  children,  never  fail  to  examine  the  ear. 

Tinnitus  aurium,  present  only  in  the  re- 
cumbent posture,  is  suggestive  of  aneurism  of 
one  of  the  posterior  cerebral  vessels. 

The  history  of  a  discharge  from  an  ear  ap- 
pearing a  few  days  to  a  few  weeks  after 
the  beginning  of  a  slowly  developing  deafness 
in  that  ear,  unaccompanied  at  any  time  by 
pain,  is  suspicious  of  tuberculous  otitis  media. 

A  bean-shaped  pulsating  swelling  just  be- 
low the  mastoid  apex,  in  cases  of  mastoiditis, 
may  be  only  a  lymphatic  gland,  but  it  may 
also  be  a  thrombosed  jugular  vein.  Its  nature 
should  therefore  be  determined  before  the 
operation  is  concluded. 

During  mastoid  operations  always  sever 
with  scissors  any  fragment  of  tissue  attached 
to  a  bit  of  bone  loosened  with  the  chisel  or 
rongeur,  before  removing  it.  The  tearing  out 
of  a  fiber  of  the  sterno-mastoid  muscle,  for 
example,  will  open  a  channel  of  mfection  in 
the  neck. 


MEAD. 


If  the  zygomatic  cells  are  thoroughly  laid 
open,  one  frequent  cause  of  persistent  sup- 
puration requiring  secondary  mastoid  opera- 
tion, may  be  avoided. 

A  persistent  elevation  of  temperature  after 
a  radical  operation  for  mastoiditis  should 
lead  one  to  suspect  the  possibility  of  a  com- 
plicating brain  abscess.  If  the  fever  shows 
wide  fluctuations  of  temperature  a  sinus 
thrombosis  is  more  probably  the  cause. 

Streptococcic  infections  having  their  en- 
trance through  the  ear  are  more  apt  to  affect 
the  muscles  than  similar  infections  with  other 
points  of  entry. 

Nitrate  of  silver  may  be  attached  in  full 
strength  to  the  end  of  a  probe,  as  for  appli- 
cation in  the  middle  ear,  by  heating  the  tip 
of  the  instrument  and  pressing  it  into  the 
stick  of  caustic;  a  little  of  the  latter  will 
melt  and  form  a  bead  on  the  probe  when  it 
cools. 

^yc.  Cystic  swellings  at  the  external   angle  of 

the  eye  are  usually  dermoids.  In  some  cases 
they  communicate  by  a  small  opening  with 
an  intracranial  sac. 


ID 


After  the  extraction  of  a  foreign  body 
from  the  cornea,  a  drop  of  castor  oil  be- 
tween the  lids  will  ameliorate  the  pam. 


HEAD. 


Severe  pain  in  the  orbit  or  even  in  the 
eye  itself  should  make  one  think  of  frontal 
sinus  infection,  especially  if  there  is,  or  re- 
cently has  been,  a  nasal  discharge.  Marked 
localized  tenderness  will  soon  confirm  the 
suspicion,  if  the  disease  exist. 


Nose. 


A  diagnosis  of  supraorbital  neuralgia 
should  not  be  made  until  frontal  sinusitis 
has  been  carefuly  excluded. 

A  persistent,  chronic  discharge  from  the 
nose  should  lead  one  to  suspect  chronic  dis- 
ease of  the  frontal  or  other  accessory  sinus. 

Transillumination  is  a  method  of  corrob- 
orative value  only  in  the  diagnosis  of  acces- 
sory nasal  sinus  disease.  By  itself  it  is  of 
small  diagnostic  use. 

Frontal  sinus  suppuration  rarely  requires 
a  disfiguring  operation  for  its  relief.  It  can 
usually  be  satisfactorily  dealt  with  through 
an  opening  in  the  line  of  the  eyebrow. 


II 


MEAD. 


Face. 


In  every  case  of  injury  to  the  nose,  with  or 
without  fracture,  it  is  well  to  examine  the 
septum  for  displacement.  If  displaced  it 
should  be  carefully  restored,  using  a  nasal 
plug,  if  necessary,  to  keep  it  in  place. 

Non-malignant  tumors  of  the  parotid  prac- 
tically never  cause  pressure  effects  on  the  fa- 
cial nerve.  This  may  be  of  importance  in 
differentiating  them   from  malignant  tumors. 

A  swelling  in  the  parotid  region  is  not 
necessarily  a  part  of  the  parotid  gland.  It 
may  be  an  infection  of  the  pre-auricular  lym- 
phatic gland.  Such  an  enlargement  may  be 
associated  with  herpes  of  the  forehead,  or, 
sometimes,  it  may  be  part  of  a  chain  of  tuber- 
culous lymph  glands. 

The  position  of  Steno's  duct  must  be  re- 
membered when  operating  on  the  face. 

In  chronic  osteomyelitis  of  the  jaw  it  is 
better  to  wait  months  for  a  sequestrum  to 
form  than  to  operate  a  dozen  times  for  the 
removal  of  necrosed  bone. 

All  swellings  of  the  lower  jaw  accom- 
panied by  discharging  fistula,  especially  mul- 


12 


HEAD, 


tiple  fistulae,  should  be  looked  upon  with  the 
suspicion  of  actinomycosis  until  proven  to  be 
otherwise. 

If  a  frightened  or  refractory  child  will  not 
open  its  mouth,  pass  a  probe  between  two 
teeth  and  back  to  the  palate.  Instantly  the 
mouth  will  open  and  a  gag  may  be  slipped 
in. 

The  employment  of  adrenalin  as  an  ap- 
plication with  cocain  to  the  mucous  mem- 
brane of  the  cheek,  e.  g.,  for  the  excision  of 
a  leukoplakic  ulcer,  is  not  to  be  advised. 
There  may  be  severe  secondary  hemorrhage. 

When  there  is  bleeding  from  the  tongue, 
post-operative  or  otherwise,  and  one  feels 
reasonably  sure  that  the  hemorrhage  is  ar- 
terial, it  can,  as  a  rule,  be  easily  arrested  by 
passing  the  forefinger  down  to  the  epiglottis 
and  hyoid  bone  and  drawing  the  base  of 
the  tongue  upward  toward  the  chin. 


riouth  and 
Pha^-ynx. 


It  is  wrong  to  perform  any  radical  opera- 
tion for  an  ulcer  of  the  tongue  without  pre- 
liminary microscopical  examination.  Clinical 
symptoms,  no  matter  how  typical,  are  often 
misleading. 


13 


HEAD. 


A  deep  ulceration  of  the  fauces  or  tonsils 
should  not  be  diagnosed  as  specific  without 
excluding  acute  lymphatic  leukemia. 

Before  operating  for  pharyngeal  adenoids 
or  hypertrophied  tonsils  make  sure  that  these 
are  not  merely  an  expression  of  status  lym- 
phaticus.  If  they  are,  do  not  employ  an 
anesthetic.  Also  determine  whether  the  pa- 
tient is  a  hemophiliac.  If  he  is,  do  not  oper- 
ate at  all. 


NECK. 


When  opening  a  retropharyngeal  or  peri- 
tonsillar abscess  in  a  small  child,  by  the 
buccal  route,  have  the  head  dependent  and 
instruments  at  hand  for  tracheotomy.  These 
instruments  are  needed  but  rarely,  but  then 
urgently. 

In  seeking  a  cause  for  torticollis,  don  t 
fail  to  examine  the  teeth. 


In  all  cases  of  torticollis,  examine  for 
caries  of  the  spine. 

Pediculosis  capitis  may  be  the  indirect 
cause  of  acute  torticollis  by  reason  of  a  de- 
veloping post-cervical  adenitis. 


14 


NECK. 


A  submaxillary  swelling  should  not  be 
dismissed  as  a  lymphatic  adenitis  without 
studying  Wharton's  duct  on  the  same  side. 
Massage  of  pus  therefrom  would  alter  that 
diagnosis. 

Examination  into  the  nature  and  cause  of 
discrete  hard  lymphatic  swellings  on  each 
side  of  the  neck,  along  the  sterno-mastoid, 
should  include  exploration  of  the  pharynx 
and  naso-pharynx  for  possible  new  growth. 

In  all  glandular  affections  of  the  neck  it  is 
quite  as  important  to  treat  the  source  of 
infection,  e.  g.,  carious  teeth,  as  to  treat  the 
inflamed  glands. 

In  **Ludwig*s  angina,"  the  cardinal  prin- 
ciple in  the  treatment  is  extensive  incision. 
An  incision  that  passes  no  matter  how  deep 
into  the  substance  of  the  submaxillary  gland 
proper,  will  prove  of  little  avail  unless  the 
tissues  within  the  wound  have  been  broken 
up  until  they  are  practically  pulpy. 

Have  the  tracheotomy  instruments  handy 
before  operating  upon  a  case  of  angina 
Ludovici. 


15 


NECK. 


The  greatest  ultimate  danger  in  cut-throat 
cases  is  the  onset  of  a  septic  pneumonia.  This 
may  be  obviated  in  a  measure  by  closing  up 
the  pharyngeal  wall,  and  by  paying  the 
strictest  attention  to  asepsis. 

In  cut-throat  wounds  where  the  thyro-hyoid 
membrane  has  been  severed,  it  is  necessary, 
in  order  to  restore  perfect  phonation  and 
deglutition,  to  suture  this  membrane  accu- 
rately. 

Avoid  the  use  of  peroxid  of  hydrogen  in 
wounds  of  the  neck.  It  is  too  apt  to  dissect 
up  the  loose  cellular  planes.  The  same  warn- 
ing applies  in  many  cases  of  cellulitis  of  the 
hand  or  foot. 

In  the  presence  of  a  hard,  diffuse,  chronic 
swelling  in  the  neck  having  some  of  the  ap- 
pearances of  a  malignant  growth,  the  possi- 
bility that  the  tumor  is  a  so-called  "woody 
phlegmon  of  Reclus"  must  be  considered. 

Hard  subcutaneous  tumors  of  the  upper 
third  of  the  neck,  with  signs  of  maHgnancy, 
are  often  epitheliomata  arising  from  branchial 
clefts. 


i6 


NECK. 


In  performing  operations  on  the  neck, 
make  the  skin  incision  parallel  to  the  muscu- 
lar plane. 


Do  not  empty  a  thyro-glossal  cyst  by  as- 
piration before  extirpating  it.  It  is  well  to 
inject  the  cavity  with  a  methylene  blue  solu- 
tion first,  in  order  to  make  sure  that  all  parts 
of  the  cyst  wall  will  be  extirpated.  Another 
method  is  to  first  empty  the  cyst  and  then 
fill  it  with  paraffin. 


In  all  operations  in  the  left  subclavian 
triangle  of  the  neck,  the  location  there  of  the 
thoracic  duct  must  not  be  forgotten. 


The  best  thing  to  do  in  such  emergencies 
as  air  embolism  is  to  apply  compression  im- 
mediately and  pour  large  quantities  of  solu- 
tion, preferably  salt  solution,  into  the  wound. 


Gradually  increasing  hoarseness  in  people 
past  middle  age,  without  definite  cause,  and 
with  a  history  of  pain  radiating  to  the  ear, 
is  suggestive  of  malignancy. 


17 


NECK. 


Tracheotomy.  Jn  urgent  cases  a  high  tracheotomy  should 

be  performed,  not  a  low  tracheotomy.  The 
former  can  be  done  very  rapidly;  the  latter 
requires  considerable  dissection. 


The  best  site  for  an  urgent  tracheotomy  is 
through  the  crico-thyroid  membrane.  To 
hold  the  opening  apart  a  couple  of  hairpins, 
bent  at  the  end,  may  be  used  as  retractors. 


In  the  performance  of  high  tracheotomy  a 
great  deal  of  room  can  be  gained  by  dividing 
transversely  the  fascia  that  extends  upward 
from  the  thyroid. 


After  tracheotomy  the  air  of  the  patient's 
room  should  be  kept  reasonably  warm  and 
moist.  Draughts  of  cold  air  provoke  much 
irritation. 


The  greatest  immediate  danger  after  a 
tracheotomy  is  the  possibility  of  a  subsequent 
pneumonia.  This  can,  in  a  large  measure, 
be  obviated  by  filtering  the  inspired  air 
through  a  soft  sponge  saturated  with  warm 
one  per  cent,  phenol  solution. 


i8 


INECK, 


Repeated  attacks  of  coughing  after  trache- 
otomy may  mean  irritation  of  the  posterior 
wall  of  the  trachea  by  the  tube;  change  the 
length  or  shape  of  the  canula. 

A  "tumor"  of  the  breast  occasionally 
proves  to  be  only  a  chronic  abscess.  It  has 
happened  that  a  breast  amputated  for  carci- 
noma has  been  found  to  be  the  seat  of  old 
abscesses  only. 

In  the  treatment  of  a  breast  abscess  the 
size  of  the  incision  is  not  as  important  as  its 
location  and  direction. 

A  small  incision  and  the  proper  employ- 
ment of  Bier's  breast  cup  will  secure  exceed- 
ingly gratifying  results  in  the  management  of 
breast  abscesses. 

In  the  presence  of  a  breast  infection  that 
fails  to  heal  within  a  reasonable  time  after 
appropriate  incision  and  dressings,  it  is  well 
to  think  of  local  tuberculosis. 

The  appearance  of  pus  in  the  breast  of  a 
woman  who  is  not,  or  has  not  recently  been 
nursing,  is  suspicious  of  some  unusual  form 
of  infection,  e.  g.,  tuberculosis. 


BREA5T, 


19 


BREAST. 


A  tender,  painful  swelling  just  at  or  be- 
yond the  upper,  outer  border  of  the  breast, 
and  near  the  edge  of  the  pectoralis  major, 
is  usually  an  inflamed  lymphatic  gland.  In 
its  presence  it  is  well  to  look  for  some  skin 
infection  about  the  waist  line,  e.  g.,  fur- 
uncles, which  are  not  rare  at  this  site  as  a 
result  of  irritation  by  the  corset.  Per  contra, 
with  a  boil,  abscess,  dermatitis  or  other  in- 
fection at  or  above  the  waist  line,  one  may 
be  on  the  lookout  for  glandular  enlargement 
at  the  point  referred  to. 

In  the  performance  of  the  radical  oper- 
ation for  breast  carcinoma  it  is  important  to 
avoid  injury  to  the  periosteum  of  the  ribs. 

Multiplicity  of  tumors  of  the  breast  usu- 
ally speaks  against  carcinoma. 

Breast  tumors,  especially  in  the  early 
stages,  not  seldom  fail  to  present  the  classi- 
cal signs  by  which  their  malignancy  or  non- 
malignancy  may  be  determined  clinically.  In 
all  cases  where  the  diagnosis  is  doubtful,  a 
specimen  of  the  tumor  should  be  removed  for 
microscopic  study,  before  undertaking  a  radi- 
cal operation. 


20 


THORAA. 


In  strapping  the  chest  for  fractured  rib, 
two  points  should  be  particularly  noted:  1. 
The  straps  should  pass  well  beyond  the  me- 
dian line.  2.  They  should  be  applied  in 
full  expiration.  One  or  two  straps  passed 
over  the  shoulder  help  much  to  secure  im- 
mobilization. 

Cold  abscess  and  lipoma  often  simulate 
each  other  very  closely,  especially  around  the 
chest.     If  in  doubt,  aspirate. 

Do  not  be  too  hasty  in  making  a  diag- 
nosis of  intercostal  neuralgia.  With  the  ex- 
ception of  pulmonary  and  pleural  conditions, 
ulcer  of  the  stomach  simulates  intercostal 
neuralgia  more  frequently  than  any  other 
lesion. 

It  is  remarkable  how  frequently  a  puru- 
lent pericarditis  may  exist  without  causing 
many  or  severe  symptoms.  Never  neglect  an 
examination  of  the  cardiac  area,  therefore, 
in  cases  of  suspected  sepsis. 

When  a  patient  complains  of  dysphagia, 
do  not  neglect  to  examine  the  pericardium 
for  effusion. 


21 


THORAA. 


A  history  of  attacks  with  symptoms  of 
esophageal  stricture  and  intervening  periods 
of  well-being  is  suggestive  of  cardiospasm. 


A  satisfactory  method  of  x-ray  study  of 
esophageal  diverticula  and  strictures  con- 
sists in  fluoroscopy  of  the  thorax  while  the 
patient  is  swallowing  an  emulsion  of  bismuth 
subnitrate.  A  skiagraph  may  be  made  im- 
mediately afterwards  as  a  supplementary 
record. 


Before  operating  for  sarcoma  examine  the 
lungs  carefully.  Do  not  operate  if  the  pa- 
tient has  persistent  cough  and  blood-stained 
sputum  (not  due  to  tuberculosis),  even 
though  no  definite  signs  are  found  in  the 
lungs — a  metastasis  has  developed. 


A  fluctuating  swelling  appearing  between 
the  ribs  may,  of  course,  be  tuberculous  or 
syphilitic  in  origin,  but  it  may  also  be  an 
extension  of  an  intrathoracic  growth,  e.  g., 
dermoid  cyst  of  the  mediastinum.  In  all  such 
cases,  therefore,  a  careful  examination,  by 
auscultation  and  percussion,  should  be  made. 


22 


TMORAA. 


A  slender  fish  bone  lodged  in  a  bronchus 
will  usually  not  cast  a  shadow  on  the  x-ray 
plate.  In  such  a  case  bronchoscopy  and  aus- 
cultation are  more  reliable  diagnostic  mea- 
sures. In  addition  to  a  variety  of  moist 
rales,  one  may  hear,  associated  with  the  in- 
spiratory or  expiratory  murmur,  or  both,  a 
musical  or  vibratory  note,  when  a  bone  or 
pin  lies  in  a  bronchus. 

If  a  patient  dates  irregular  or  persistent 
cough  from  a  time  when  he  thinks  he  "swal- 
lowed" or  inspired  a  foreign  body,  the  fact 
that  the  physical  signs  elicited  upon  examina- 
tion of  the  chest  are  peculiar — different  from 
those  found  in  ordinary  types  of  bronchitis 
— points  strongly  to  the  presence  of  a  for- 
eign body. 

Bronchiectasis  is  not  seldom  complicated 
by  brain  abscess. 

In  aspirating  the  chest,  see  to  it  that  the 
syringe  is  in  good  condition  before  inserting 
the  needle.  Never  apply  the  syringe  to  the 
needle  after  the  latter  has  been  inserted;  a 
severe  pneumothorax  may  result.  If  the 
syringe  is  found  to  be  out  of  order  while 
the  aspiration  is  being  done,  withdraw  the 
needle  also  and  reinsert. 

23 


THORAA. 


There  is  one  point  that  must  always  be 
thought  of  when  pus  has  been  aspirated  after 
an  exploratory  puncture  for  either  suspected 
empyema  or  liver  abscess, — to  make  sure 
that  the  "pus"  does  not  come  from  a  bron- 
chus. This  can  be  determined,  as  a  rule,  by 
microscopical  examination  of  the  aspirated 
fluid. 

Very  extensive  and  rapidly  spreading  sub- 
cutaneous infections  may  result  after  an  aspi- 
ration of  a  foul-smelling  empyema.  It  is 
therefore  wise  to  always  operate  over  the 
site  of  aspiration,  and  especially  to  see  that 
the  puncture  wound  is  well   drained. 

When  operating  for  empyema  thoracis  it 
is  a  good  rule  to  aspirate  again  when  the 
pleura  is  exposed  and  before  it  is  incised. 
This  may  save  some  embarrassment. 

The  shock  of  evacuating  an  empyema  tho- 
racis may  be  largely  avoided  by  making  but 
a  small  opening  in  the  pleura  (after  resect- 
ing the  rib)  and  applying  at  once  several 
thicknesses  of  gauze.  At  the  next  dressing 
much  or  most  of  the  pus  will  be  found  to 
have  escaped  into  the  gauze,  and  the  pleural 
wound  may  then  be  enlarged  without  produc- 
ing shock. 

24 


THOKAA. 


After  operation  for  empyema,  a  cover  of 
oiled  silk  or  gutta-percha  over  the  gauze 
dressing  serves  to  prevent  admission  of  air 
into  the  pleural  cavity,  while  it  will  not  in- 
terfere with  the  escape  of  air  already  in 
the  chest.  Indeed,  a  flap  of  rubber  may  be 
laid  over  the  wound  and  fastened  with  a 
little  chloroform  above.  This  allows  pus 
to  escape  from  beneath  it  and  excludes  the 
admission  of  air. 


It  is  surprising  how  much  information  can 
be  derived  by  abdominal  palpation  conduct- 
ed with  the  patient  in  a  hot  bath,  the  temper- 
ature of  the  water  being  gradually  raised  to 
105°  F.  It  usually  secures  as  much  relaxa- 
tion as  does  the  administration  of  an  anes- 
thetic, sometimes  even  more.  In  addition  to 
the  avoidance  of  the  dangers  and  the  dis- 
agreeable features  of  narcosis,  it  has  the  im- 
portant advantage  that  the  patient  is  able  to 
call  the  examiner's  attention  to  sensitive  areas. 


ABDOriEN. 


In  the  presence  of  a  tumor  in  the  mid- 
line between  umbilicus  and  pubes,  the  pos- 
sibility of  a  cyst  of  the  urachus  must  be 
borne  in  mind.  It  may  simulate  an  ovarian 
cyst  or  other  tumor,  or  a  distended  bladder. 


25 


ABDoneiN. 


Eczema  of  the  umbilicus  is  sometimes 
merely  the  expression  of  an  infected  dermoid 
cyst  at  that  site. 

A  discharge  from  the  umbilicus  may  be 
due  to  an  infected  dermoid  cyst,  to  an  ec- 
zema of  the  umbilicus,  to  a  patent  urachus 
(urine),  to  a  cyst  of  the  urachus  (milky 
discharge)  ;  it  may  be  of  pus  from  an  ab- 
scess within  the  abdomen  or  in  the  abdomin- 
al wall,  or  of  feces  (Meckel's  diverticulum, 
perforated  strangulated  hernia,  fecal  abscess 
from  tuberculosis). 

Do  not  ligate  tumors  of  the  navel  without 
making  sure  that  the  intestine  is  not  included 
within  the  ligature. 

In  performing  paracentesis  in  the  median 
line  for  abdominal  fluid,  be  sure  that  the 
bladder  is  empty.  When  it  is  necessary  to 
perform  paracentesis  in  the  lateral  part  of  the 
abdomen,  be  careful  to  avoid  the  deep  epi- 
gastric artery. 

Unless  some  other  cause  is  evident  don't 
fail  to  examine  for  signs  of  tabes  when  an 
adult  complains  of  pains  about  the  waist, 
in  the  back  or  in  the  lower  extremities. 


26 


ABDOriEN. 


Children  who  complain  frequently  of  pain 
in  the  stomach  should  be  examined  for  evi- 
dence of  beginning  Pott's  disease.  Such 
cases,  treated  before  the  development  of  cur- 
vature, usually  yield  very  satisfactory  results. 

In  all  cases  of  acute  abdominal  pain,  never 
fail  to  examine  the  lungs  and  gums.  The 
onset  of  pneumonia  or  pleurisy  frequently 
closely  simulates  acute  appendicitis;  lead 
colic  may  simulate  almost  any  painful  ab- 
dominal condition. 

Enlargement  of  the  veins  at  the  side  of  the 
abdomen  is  indicative  of  obstruction  to  the 
flow  of  blood  in  the  inferior  vena  cava;  dis- 
tention of  veins  about  the  umbilicus  sug- 
gests obstruction  in  the  portal  circulation. 
The  former  may  be  associated  with  varices 
of  the  lower  extremities,  the  latter  with 
hemorrhoids. 

In  all  cases  of  recurrent  vomiting  examine 
the  midline  of  the  abdomen  for  a  small  epi- 
gastric hernia. 

Catheterization  sometimes  makes  the  evi- 
dences of  "appendicitis"  or  "abdominal  tu- 


27 


ABDOriEIN. 


mor"   vanish   with    the   escape   of   the   urine 
from  a  distended  bladder. 

In  cases  of  run-over  by  vehicles,  if  the 
wheels  pass  over  the  trunk  from  right  to 
left  the  liver  is  the  organ  most  commonly 
ruptured,  whereas,  if  the  wheels  pass  from 
left  to  right  the  spleen  is  more  frequenti)' 
injured. 

The  hypodermatic  injection  of  eserin 
(salicylate)  gr.  1/30 — 1/40,  during  or  just 
after  an  abdominal  operation,  will,  in  most 
cases,  entirely  or  largely  prevent  the  distress- 
ing tympanites  that  otherwise  usually  occurs. 

A  pulsating  swelling  in  the  midline  of  the 
abdomen  should  not  be  too  quickly  accepted 
as  an  aneurism  of  the  aorta.  It  may  be  a 
retroperitoneal  tumor. 

In  the  presence  of  large  masses  of  glands 
in  the  epigastrium,  especially  on  the  right 
side,  examine  the  testicles  for  new  growth. 

Large,  slowly  growing,  slightly  movable 
abdominal  tumors  near  the  median  line,  caus- 


28 


ABDOriEN 


ing  few  symptoms  and  not  accompanied  by 
signs  of  malignancy,  are  suggestive  of  mesen- 
teric cysts. 

A  primary  tumor  of  the  lateral  abdomi- 
nal region  in  infants  and  young  children  is 
usually  a  sarcoma  of  the  kidney. 

In  operating  for  perforating  gun-shot 
wounds  of  the  abdomen,  find  the  source  of 
any  bleeding  first,  before  attempting  to  suture 
any  perforation. 

In  suturing^  the  fascial  layers  of  the  ab- 
dominal wall  do  not  take  too  large  bites 
with  the  needle.  Necrosis  may  occur,  and 
sloughing  of  the  fascia  predisposes  to  the 
formation  of  hernia. 

If  there  is  repeated  vomiting  and  the  pa- 
tient shows  some  evidences  of  collapse,  after 
a  laparotomy,  especially  after  operations  in 
the  gastric  region,  examine  for  separation  of 
the  wound  and  prolapse  of  the  abdominal 
contents. 

In  children,  in  cases  of  peritonitis  of  un- 
known origin,  examine  for  gonorrheal  vulvo- 
vaginitis. 

29 


ABDOriEN. 


Steady  loss  of  weight  without  other  de- 
monstrable cause  should  lead  the  physician 
to  look  for  a  possible  malignant  visceral  neo- 
plasm. Persistent  "indigestion"  due  to  some 
condition  not  positively  ascertained,  should  be 
submitted  to  surgical  diagnosis. 


Bile  Tract. 


Repeated  attacks  of  "indigestion,"  not  ob- 
viously due  to  some  other  condition,  should 
awaken  the  suspicion  of  gall-stones.  Most  of 
the  patients  operated  upon  for  cholelithiasis 
give  a  history  of  having  been  treated  for  a 
long  time  for  "dyspepsia,"  and  in  many  of 
these  cases  the  correct  diagnosis  might  ear- 
lier have  been  established. 


If  pressure  in  the  right  hypogastrium  gives 
rise  to  a  referred  pain  in  the  shoulder  region, 
the  offending  area  is  probably  the  gall- 
bladder and  not  the  pylorus. 

In  an  attack  of  cholelithiasis  the  vomiting 
as  a  rule  is  not  attended  by  relief  of  pain; 
the  contrary  is  true  in  ulcer  of  the  stomach. 

In  differentiating  between  gastric  ulcer 
and  gall-stone  pains,  the  association  of  a  chill 
usually  points  to  cholelithiasis. 


30 


ABDOriEN, 


Tuberculosis  and  cholelithiasis  are  only 
very  rarely  associated. 

Long  pauses  between  attacks  of  gastric 
or  abdominal  pain  speak  in  favor  of  chole- 
lithiasis. 

In  the  progress  of  a  cholecystectomy,  if  a 
stone  slips  away  after  cutting  through  the 
cystic  duct,  and  cannot  be  found,  no  great 
anxiety  need  be  felt,  for  the  stone  usually 
comes  away  spontaneously  in  the  subsequent 
discharge. 

Great  pain  following  any  operation  upon 
the  biliary  tract  should  always  lead  one  to 
suspect  leakage  of  bile  into  Morrison's  space. 
If  such  should  be  found  to  be  the  case  insert 
a  drainage  tube. 

When  operating  for  cholelithiasis,  don't 
fail  to  examine  the  hepatic  duct. 

When  palpating  the  common  bile  duct  for 
stone,  make  sure  that  a  suspected  calculus 
is  not  a  gland. 

In  catarrhal  icterus  the  pulse  is  usually 
slow;  in  jaundice  from  cholelithiasis  this  is 
usually  not  the  case. 


31 


ABDoneiN. 


Gradually  increasing  jaundice  without 
previous  history  of  pain,  or  with  a  history 
of  very  slight  pain,  is  very  suggestive  of 
mahgnant  disease. 

Before  attributing  enlargement  of  the  liver 
to  a  surgical  condition  exclude  chronic  hep- 
atic congestion  of  cardiac  disease. 

Examine  the  rectum  in  all  cases  of  tumor 
of  the  liver.  Likewise,  before  operating  for 
cancer  of  the  rectum  examine  the  liver  for 
metastasis. 

5tomach.  Examination    to    determine    the    possible 

presence  of  cardiac  disease  or  aneurism 
should  always  be  made  before  passing  a 
stomach  tube.  In  the  presence  of  such  le- 
sions the  tube  should  not  be  employed  ex- 
cept as  a  life-saving  measure  in  an  emer- 
gency. 

A  hasty  diagnosis  of  ulcer  of  the  stomach 
should  not  be  made  merely  because  the  pa- 
tient has  vomited  suddenly  large  quantities 
of  blood.  If  the  bleeding  occurs  at  regular 
intervals  the  possibility  of  vicarious  menstru- 
ation must  be  considered. 


32 


ABDOMEN. 


It  is  well  to  remember  that  not  all  ulcers 
of  the  stomach  are  characterized  by  the 
classical  symptoms  of  pain,  vomiting  and 
hemorrhage.  Many  patients  presenting 
"dyspeptic"  symptoms  of  only  mild  grade 
are  afflicted  with  this  disease,  and  such  cases 
may  easily  be  diagnosed  as  functional  disor- 
ders until  the  persistence  of  the  symptoms 
leads  one  to  suspect  the  graver  malady. 

The  thirst  following  a  hemorrhage  from 
gastric  ulcer  is  best  relieved  by  small  quan- 
tities of  cocain  in  solution. 

If  an  undoubted  case  of  ulcer  of  the  stom- 
ach is  associated  with  chills,  in  most  cases  it 
means  that  the  ulcer  is  adherent  to  the  spleen. 

A  sudden  desire  for  sharp,  sour  and  spicy 
articles  of  food  in  a  middle-aged  or  elderly 
person  is  often  the  first  symptom  of  a  be- 
ginning gastric  carcinoma. 

In  a  case  of  gastric  disease  of  doubtful 
diagnosis,  progressive  loss  of  weight  js  the 
most  important  sign  in  determining  the  prob- 
abihty  of  carcinoma. 


33 


ABDOMEN. 


The  possibility  of  gastric  cancer  must  be 
considered  in  cases  of  supposed  pernicious 
anemia. 

In  persons  of  middle  age  presenting  gas- 
tric symptoms,  the  diagnosis  of  cancer  should 
not  be  excluded  because  the  symptoms  have 
had  a  sudden  onset.  Such  an  onset  occurs  in 
a  fair  proportion  of  cases. 

Vomiting,  secondary  anemia  and  absence 
of  free  hydrochloric  acid  in  the  gastric  juice 
— a  triad  of  symptoms  at  once  suggestive  of 
carcinoma  ventriculi — may  occur  as  a  result 
of  chronic  nephritis.  Especially  if  the  urine 
contain  no  casts  or  albumin  is  the  observer 
apt  to  be  led  astray. 

If  a  patient  vomits  coffee-ground  material 
in  w^hich  no  lactic  acid  is  present,  one  can 
almost  always  exclude  carcinoma. 

A  reasonable  suspicion  of  the  presence  of 
a  cancer  in  the  stomach  or  intestine  is  suffi- 
cient indication  for  explorative  operation. 

Before  proceeding  with  a  radical  operation 
for  carcinoma  of  the  stomach,  examine  not 


34 


ABDOMEN. 


only  the  liver  but  also  the  general  abdominal 
cavity,  especially  the  pelvis,  and  in  females 
the  ovaries,  for  any  sign  of  metastasis. 

Do  not  be  too  sure  that  a  mass  in  the  re- 
gion of  the  pylorus  is  a  carcinoma.  In  some 
cases  the  infiltration  around  a  chronic  ulcer 
is  very  extensive  and  may  simulate  the  feel 
of  a  new  growth. 

If  a  patient  begins  to  vomit  long  after  a 
radical  operation  for  carcinoma  of  the  stom- 
ach, do  not  jump  to  the  conclusion  that  the 
cause  is  a  local  recurrence.  It  may  be  a 
metastasis  in  the  brain. 

In  a  patient  with  spondylitis,  symptoms 
simulating  acute  peritonitis  may  be  due  to 
acute  dilatation  of  the  stomach. 

The  occurrence  after  laparotomy  of  marked 
distention  of  the  upper  abdominal  zone,  vom- 
iting and  collapse  points  to  acute  dilatation 
of  the  stomach. 

It  is  a  peculiar  fact  that  post-operative 
prolapse  through  the  epigastric  wound  occurs 
frequently  in  operations  for  malignant  disease 


35 


ABDOriEIN. 


of  the  stomach.  Such  wound  therefore  should 
be  closed  with  more  than  usual  firmness  and 
all  possible  precautions  should  be  taken  to 
guard  against  post-operative  vomiting. 

In  performing  posterior  gastro-enterostomy 
see  that  the  opening  in  the  transverse  meso- 
colon is  not  so  narrow  that  it  may  constrict 
the  anastomosed  segment  of  small  intestine 
nor  yet  so  large  that  it  may  permit  of  a 
possible  hernia  into  the  lesser  sac.  By  in- 
serting a  number  of  sutures  between  the  meso- 
colon and  the  stomach  wall  about  the  anas- 
tomosis these  possibilities  may,  in  large  part, 
be  obviated. 

If  within  a  week  or  two  after  the  perfor- 
mance of  gastrostomy  the  drainage  tube 
should  be  expelled  from  the  fistula,  do  not 
entrust  its  re-introduction  to  inexperienced 
hands.  It  has  sometimes  happened  that  the 
tube  has  been  pushed  into  the  peritoneal 
cavity,  instead  of  into  the  stomach. 

Intestines.  In  the  presence  of  anemia  or  of  faintness, 

without  other  apparent  cause,  inquire  con- 
cerning the  passage  of  black  stools.  The 
condition  may  result  from  hemorrhages  due 


36 


ABDOriEIN. 


to  an  ulcer  or  neoplasm  of  the  small  intes- 
tine. 

A  gradually  increasing  anemia  in  an  eld- 
erly person,  without  any  other  symptoms,  is 
highly  suggestive  of  a  latent  carcinoma,  often 
in   the   intestine. 

In  typhoid  fever  spontaneous  rupture  of 
the  spleen  ma}^  simulate  intestinal  perforation. 

The  triad  of  symptoms — pain,  vomiting 
and  distention — without  fever,  points  to  in- 
testinal obstruction. 


Attacks  of  abdominal  pain  preceded  by 
"rumbling"  of  the  bowels  is  suggestive  of 
some  obstructive  condition. 

The  passage  of  gas  or  even  of  a  small 
amount  of  feces,  after  an  enema,  does  not 
gainsay  the  presence  of  intestinal  obstruction. 

In  an  acute  condition  simulating  intesti- 
nal obstruction,  if  a  large  mass  can  be  felt  in 
the  abdomen  think  of  omental  torsion. 


37 


ABDOMEN. 


An  attack  of  acute  intestinal  obstruction, 
with  passage  of  blood,  and  in  the  presence 
of  a  cardiac  lesion,  is  suggestive  of  throm- 
bosis of  a  mesenteric  vessel. 

Every  case  of  intestinal  obstruction  of  ob- 
scure origin  should  be  inquired  into  closely 
with  reference  to  a  previous  history  of  chole- 
lithiasis. If  a  definite  history  of  this  is  ob- 
tained, it  is  well  to  suspect  obstruction  by  a 
gall-stone. 

When  operating  for  volvulus  of  the  large 
intestine,  insert  a  rectal  tube  as  high  up  as 
possible  before  attempting  the  reduction. 
The  volvulus  will  quickly  collapse  and  the 
necessity  for  evisceration  will  thus  be  avoid- 
ed. 

In  infants  sudden,  severe  colic  associated 
with  diarrhea  or  the  passage  of  small  quan- 
tities of  blood,  should  lead  one  strongly  to 
suspect  an  intussusception. 

When  reducing  an  intussusception  don't 
pull  on  the  intussusceptum  but  push  on  the 
intussuscipiens. 

38 


ABDOMEN. 


Whenever  we  meet  with  a  movable,  saus- 
age-shaped mass  in  the  abdomen,  with  a 
history  of  chronicity,  it  is  well  to  think  of  the 
possibihty  of  its  being  a  case  of  hyperplastic 
tuberculosis  of  the  intestine.  This  diagnosis 
will  be  rendered  more  suggestive  if  there  are 
definite  signs  in  the  lungs. 

Simple  or  multiple  enterostomy,  usually 
with  prompt  suture  of  the  opening,  is  many 
times  a  life-saving  operation  in  the  presence 
of  intestinal  paresis,  as  from  general  periton- 
itis. 


At  the  onset  of  an  attack  of  acute  appen- 
dicitis the  pain  is  usually  referred  to  the  gas- 
tric region. 


Appendix. 


The  cessation  of  severe  pain  during  the 
course  of  acute  appendicitis  often  means  per- 
foration. 

The  twisting  of  the  pedicle  of  a  small 
ovarian  cyst  may  simulate  both  the  symp- 
toms and  signs  of  attacks  of  appendicitis. 

The  tenderness  in  appendicitis  may  not  be 
(probably  usually  is  not)    just  at  McBur- 


39 


ABDOMEN. 


ney's  point.  The  base  of  the  appendix  is, 
however,  usually  at,  or  near,  that  point.  The 
site  of  greatest  ienderness  is  often  over  the 
tip  of  the  appendix.  A  line  drawn  between 
that  site  and  McBurney's  point  will  many 
times  represent  the  general  direction  in 
which  the  appendix  is  lying. 


In  cases  of  chronic  appendicitis,  if  an  ex- 
amination be  conducted  with  the  patient  in 
a  hot  bath  (105°  F. ) ,  the  thickened  appen- 
dix may  often  be  felt  to  roll  under  the  finger. 


In  a  tuberculous  patient  with  supposed 
chronic  appendicitis  it  is  well  to  suspect  tub- 
erculous disease  of  the  ileo-cecal  valve. 


Mcrnia.  It   is   a   wise  rule  never  to   attempt  taxis 

in  cases  of  strangulated  hernia.  The  only 
exception  might  possibly  arise  in  a  case  seen 
within  the  first  hour. 


All  cases  of  hernia  in  which  there  is  a 
history  of  frequent  urination  should  lead  one 
to  the  suspicion  that  the  hernial  sac  contains 
part  of  the  bladder. 


40 


ABDOMEN. 


If  a  peculiar  looking  mass  is  found  at  the 
inner  side  of  the  ring  in  the  course  of  an 
operation  for  inguinal  hernia,  do  not  incise 
or  dissect  it  before  convincing  yourself  that 
it  is  not  the  bladder. 

Do  not  be  too  hasty  in  resecting  a  strangu- 
lated loop  of  intestine.  It  is  remarkable  how 
frequently  such  loops  become  viable  after 
long  continued  applications  of  hot  saline  so- 
lution. 

Examine  the  umbilicus  and  the  inguinal 
and  femoral  canals  in  all  cases  of  obscure 
intestinal  obstruction.  Small  strangulated 
femoral  hernias  often  simulate  very  closely 
the  feel  and  appearance  of  a  gland,  and  in 
such  cases  one  may  be  easily  misled. 

In  hgating  the  omentum,  it  is  a  good  rule 
never  to  place  a  ligature  around  a  piece 
larger  than  the  width  of  a  finger. 

Hemorrhage  from  the  bowel  in  children  is 
not  infrequently  caused  by  a  polypus  in  the 
rectum. 

Prolapsus  ani  is  a  frequent  accompaniment 
of  bladder  stone  in  children. 


KECTUn. 


41 


RECTUri. 


Prolapse  of  the  rectum  in  children  usually 
yields  to  treatment  by  strapping  the  nates 
together  with  adhesive  plaster,  if  carried  out 
intelligently  and  persistently,  for  several 
weeks  or  months.  The  child  should  be 
obliged  to  defecate  in  the  recumbent  posture 
and  while  the  strap  is  on.  After  defeca- 
tion the  strap  is  removed,  the  parts  cleansed 
and  a  fresh  strap  applied,  all  while  the 
child  is  recumbent. 

A  mass  protruding  from  the  rectum  of  an 
infant  or  child  may  be  an  intussusception  and 
not  a  mere  prolapse. 

Don't  fail  to  make  a  digital  rectal  exami- 
nation in  cases  of  appendicitis  and  in  all  ail- 
ments when  the  diagnosis  is  obscure.  Nor 
should  it  ever  be  omitted  before  an  opera- 
tion upon  anal  disorders.  It  may  save  the 
embarrassment  of  a  subsequent  discovery  that 
a  patient's  hemorrhoids,  for  example,  were 
but  an  expression  of  a  carcinoma  higher  up 
in  the  rectum. 

A  radical  operation  for  hemorrhoids 
should  not  be  undertaken  until  the  etiology 
of   the  piles   has   been    determined.      Some- 


42 


RECTUn. 


times  the  cause  is  an  obstruction  in  the  por- 
tal circulation  due  to  hepatic  disease.  Per 
contra,  abscess  of  the  liver  may  be  due  to  in- 
fection from  a  hemorrhoid  operation  perform- 
ed even  some  months  before. 

Bleeding  from  capillary  hemorrhoids  high 
in  the  rectum  usually  yields  to  injections  of 
cold  water,  or  a  cold  solution  of  tannic  acid. 
In  these  cases,  however,  it  is  important  to 
exclude  the  presence  of  an  ulcer  further  up. 

If  a  thrombosing  pile  is  opened  before 
the  clotting  is  complete,  it  is  very  apt  to  fill 
up  again  and  may  even  become  edematous 
and  inflamed. 

When  removing  hemorrhoids  much  after- 
pain  may  be  obviated  by  making  radiating 
nicks  in  the  skin  margin  of  the  anus. 

After  an  operation  for  hemorrhoids  it  is 
desirable  to  insert  into  the  rectum  a  tampon 
canula,  made  by  smearing  with  vasehn  gauze 
layers  wrapped  about  a  piece  of  rubber 
tubing,  about  three  inches  long  and  trans- 
fixed at  its  distal  extremity  with  a  large 
safety  pin.      The    tampon    canula    prevents 


43 


RECTUM. 


oozing  by  its  gentle  pressure,  allows  any  con- 
siderable hemorrhage  to  show  itself  extern- 
ally, makes  the  escape  of  flatus  painless  and 
the  introduction  of  an  oil  enema  easy. 

Although  profound  anesthesia  is  required 
to  abolish  the  anal  reflex,  chloroform  or  ether 
is  not  always  needed  in  order  to  divulse  the 
sphincter  ani.  This  may  be  accomplished 
painlessly,  and  usually  with  fair  satisfac- 
tion, under  ethyl  chlorid  or  nitrous  oxid  nar- 
cosis if,  especially,  an  opium  suppository  is 
introduced  a  half-hour  beforehand,  and  a 
pledget  of  cotton  wet  in  cocain  solution  is 
applied  just  before  the  operation. 

After  operations  upon  the  rectum,  espe- 
cially after  those  involving  divulsion  of  the 
sphincter  ani,  voluntary  urination  is  apt  to  be 
inhibited  for  a  day  or  more.  This  is  especi- 
ally the  case  when  stretching  is  done  in  a 
Scgittal  direction,  i.  e.,  towards  the  urethra 
and  the  coccyx.  It  may  save  catheterization, 
therefore,  if  the  stretching  is  done  only 
laterally,  i.  e.,  towards  the  tubera  ischii. 

When  pruritus  ani  is  caused  by  a  local 
eczema  it  is  well  to  remember  that  the  latter 


44 


may  be  seborrheal  in  origin.  In  such  cases 
other  areas  of  the  disease,  as  on  the  chest 
and,  especially,  the  scalp,  should  be  sought 
for;  they  will  require  attention  also,  in  order 
to   effect  a  cure. 


RECTUn. 


It  is  not  sufficiently  established  that  the 
character  of  the  crystals  found  in  the  urine 
indicates  the  presence  or  identity  of  lithiasis 
in  the  urinary  tract.  When  cystin  crystals 
are  constantly  found  in  the  sediment,  how- 
ever, if  symptoms  of  lithiasis  are  present,  the 
stone  is  probably  made  up  of  cystin. 


OENITO. 

URINARY 

TRACT. 


Kidney  and 
Ureter. 


An  approximate  determination  of  the  or- 
igin of  a  hematuria  may  be  obtained  by  not- 
ing the  following  points:  If  pure  blood  is 
followed  by  clear  urine,  the  origin  is  in  the 
urethra;  if  the  patient  first  passes  urine,  then 
blood,  the  source  of  bleeding  is  probably  in 
the  bladder;  if  urine  evenly  mixed  with 
blood  is  voided,  the  kidney  is  probably  re- 
sponsible for  the  hemorrhage;  if  long,  fine 
clots  resembling  worms  are  passed,  these, 
usually,  are  from  the  ureter. 

A  point  worth  remembering  in  the  diag- 
nosis of  nephrolithiasis  is  that  red  blood  cells 


45 


OENITOURIINARy  TRACT. 


are  almost  always  found  in  the  centrifuga- 
lized  sediment  in  the  urine  even  in  the  inter- 
val between  attacks  of  colic. 

In  a  very  acid  urine  red  blood  cells  may  be 
disintegrated  and  appear  under  the  microscope 
as  an  amorphous  material.  When  it  is  im- 
portant to  determine  the  presence  or  absence 
of  blood  in  the  urine  it  is  sometimes  neces- 
sary, therefore,  to  resort  to  a  chemical  test, 
e.  g.,  that  with  guaiac  resin. 

A  radiographic  shadow  simulating  that  of 
a  urinary  calculus  may  be  produced  by  an 
atheromatous  plaque,  as,  for  example,  in  the 
internal  iliac  artery,  by  a  phlebolith,  or  by 
a  calcareous  gland. 

When  skiagraphing  for  suspected  renal 
calculus  the  entire  urinary  tract  should  be 
exp)osed,  i.  e.,  the  kidney  regions,  ureters 
and  bladder.  Not  infrequently  a  stone  sup- 
posed to  be  in  the  kidney  may  be  lodged  in 
the  lower  end  of  the  ureter,  within  reach 
from  the  bladder. 

By  a  careful  study  of  an  x-ray  plate  it 
can  usually  be  determined  with  fair  accuracy 


46 


OCNITOURIINARY  TRACT. 


whether  a  renal  calculus  is  in  the  pelvis  or  in 
the  parenchyma,  at  the  upper  pole  or  the 
lower  pole. 

In  cases  of  renal  colic  do  not  make  too 
positive  a  pre-operative  diagnosis  of  calculus, 
no  matter  how  typical  the  symptoms  may  be. 
It  has  happened  very  often  at  the  time  of 
operation  that  no  stone  is  found.  Fortun- 
ately, these  cases  are  nearly  always  cured 
by  the  exploratory  nephrotomy. 

Attacks  of  abdominal  pain  associated  only 
with  intestinal  symptoms,  may  nevertheless 
be  due  to  a  renal  or  ureteral  calculus,  even 
though,  in  addition,  a  tender  area  may  be 
palpated  at  a  point  more  or  less  remote  from 
the  kidney  regions. 

The  perinephric  space  is  a  frequent  site  of 
metastatic  inflammation  after  furunculosis  or 
other  septic  infection. 

If  possible,  always  tie  each  component  of 
a  kidney  pedicle  separately,  not  en  masse. 

If  a  stump  ligature,  e.  g.,  of  the  renal  pe- 
dicle, is  slow  to  come  away,  the  process  may 


47 


OENlTO=URINARy  TRACT. 


be  hastened  by  fastening  it  taut  to  a  piece  of 
rubber  tubing  stretched  across  the  wound. 

If  pus  persists  in  the  urine  after  the  extir- 
pation of  a  kidney  for  suppurative  disease, 
it  often  means  that  the  ureter  is  involved  and 
will   require   subsequent    extirpation. 

When  operating  upon  the  ureter  for  cal- 
culus or  stricture,  avoid  undue  manipulation; 
it  is  important  to  prevent  detachment  of  the 
ureter  from  its  bed,  if  possible. 

Pyuria  without  symptoms  is  suspicious  of 
an  early  tuberculosis  of  the  urinary  tract. 

The  examination  for  tubercle  bacilli  in  the 
urine  by  the  ordinary  method  of  staining,  is 
not  decisive  by  any  means,  even  if  the  blad- 
der has  been  catheterized  and  differential 
stains  for  smegma  bacilli  have  been  em- 
ployed. Numerous  examinations  with  the 
aid  of  these  procedures  must  be  made,  and 
even  then  the  diagnosis  is  only  a  presumptive 
one.  The  only  sure  test  is  by  injecting  a 
large  quantity  of  the  sediment  into  a  guinea- 
pig. 


48 


OEINITO-URINAR/  TRACT. 


Most  cases  of  sudden,  unexpected  hemor-  Bladder, 
rhage  from  the  urethra  are  due  to  mahgnant 
disease,  but  it  is  well  to  remember  that  there 
are  cases  of  genito-urinary  tuberculosis  in 
which  such  a  hemorrhage  is  the  first  symp- 
tom. 

Hemorrhage  from  the  bladder  may  yield 
to  irrigations  with  ice-cold  water  and  with 
1-10,000  adrenalin  solution,  successively. 

Never  attempt  to  pack  a  bladder  for 
hemorrhage  without  the  aid  of  guy  sutures: 
with  them  one  can  make  absolutely  sure  that 
the  gauze  goes  into  the  bladder,  and  not  on 
top  of  it,  pushing  the  organ  away  from  the 
space  of  Retzius. 

Post-operative  hemorrhage  from  the  base 
of  the  bladder  that  proves  inaccessible  to  lig- 
atures, and  uncontrollable  by  packings,  may 
be  checked  by  the  following  method: 
Through  several  thicknesses  of  gauze,  cut 
in  squares,  pass  a  double  strand  of  heavy 
silk  or  of  twine  fastened  on  a  stout  needle. 
With  the  patient  in  Trendelenburg's  position 
and  the  bladder  widely  opened,  thrust  the 
needle  from  within  directly  through  the  per- 
ineum, and  bring  the  gauze  firmly  against  the 


49 


OEINITO-URINARY  TRACT 


bleeding  surface  by  pulling  upon  the  threads, 
which  are  then  to  be  fastened  to  an  out- 
side dressing. 

It  is  a  peculiar  fact  that  many  of  the  cases 
of  tumor  of  the  bladder  occur  among  work- 
ers in  anilin  dyes. 

It  should  be  borne  in  mind  that  stone  in 
the  bladder  may  be  the  primary  cause  in 
children  of  enuresis,  masturbation  or  prolap- 
sus recti. 

What  feels  at  the  other  end  of  the  search- 
er like  a  stone  in  the  bladder,  may  be  a  fold 
of  mucous  membrane  encrusted  with  urinary 
deposit. 

In  cases  of  suspected  rupture  of  the  blad- 
der, catheterization  is  not  always  a  sure  test. 
The  rent  may  be  so  large  that  the  catheter 
draws  away  urine  that  has  already  flowed 
into  the  peritoneal  cavity. 

To  prevent  a  suprapubic  or  other  drain- 
age tube  from  becoming  displaced  is  easily 
accompHshed  by  fitting  another  tube  over  it 
hke  a  collar;  this  outer  tube  is  split  through 


50 


OCNITO=URirSAR/  TUACT. 


half  its  length  and  the  two  portions  are 
spread  out  over  the  skin  and  fastened  down 
with  adhesive  plaster. 

Involuntary  urination  very  often  means  a 
distended  bladder,  and  in  old  men  it  should 
at  once  indicate  an  examination  into  the  con- 
dition of  the  prostate.  Vomiting,  too,  is 
often  caused  by  distention  of  the  bladder. 

An  acutely  distended  bladder  should  not 
be  completely  emptied  in  one  sitting.  Its 
rapid  collapse  may  produce  hemorrhagic  cys- 
titis. 

Before  employing  a  rubber  catheter  test 
its  resihency.  If  it  is  brittle  or  cracked,  dis- 
card it.  Not  infrequently  a  rotten  catheter 
breaks  off  in  the  bladder  while,  of  course, 
a  rough  catheter  or  sound  may  play  havoc 
in  the  urethra. 

Unconscious  patients  should  be  catheter- 
ized  at  regular  intervals  of  about  eight  hours. 

Rectal  examination  sometimes  aids  in  de-    Prostate. 
termining  the  variety  of  obstruction  in  pros- 
tatic hypertrophy.      If  the  prostate  is  com- 


51 


OEINITO-URINARY  TRACT. 


paratively  small,  the  obstruction  is  probably 
due  to  the  middle  lobe;  if  large,  to  the  later- 
al lobes. 


A  Mercier  catheter  is  the  first  kind  that 
ought  to  be  employed  in  attempting  to  over- 
come retention  caused  by  an  enlarged  pros- 
tate. Often  it  will  have  to  be  resorted  to 
in  the  end;  and,  therefore,  it  will  save  much 
unsuccessful  manipulation  to  use  it  at  once. 
Occasionally,  a  metal  catheter  will  pass 
when  even  a  Mercier  fails. 

Never  open  a  prostatic  abscess  per  rectum; 
no  matter  how  much  it  bulges;  always  oper- 
ate through  the  perineum. 

It  is  a  wise  rule  to  submit  all  removed 
hypertrophied  prostates  to  thorough  examina- 
tion by  a  pathologist.  Carcinomatous  de- 
generation may  be  found  in  some  spot. 

Carcinoma  of  the  prostate  often  does  not 
recur  for  some  time;  meanwhile  the  patient 
may  look  surprisingly  well.  This  should  not 
beguile  the  surgeon  into  a  too  hopeful  prog- 
nosis. 


52 


OENITO^URirSARy  TKACT. 


Force  is  never  helpful  in  overcoming  the  Penis  and 
resistance  of  a  stricture  to  instrumental  pas-  Urethra. 
sage;  it  is  bound  to  do  harm.  A  combina- 
tion of  patience  and  hot  apphcations,  with 
a  strong  admixture  of  gentleness  and  judg- 
ment, will  effect  the  desired  result  in  most 
cases. 

A  swelling  or  redness  behind  the  scrotum, 
in  cases  of  urethral  stricture  or  developing 
after  urethral  instrumentation,  usually  means 
urinary  extravasation,  which  requires  prompt 
and  active  treatment. 

One  death  from  urethral  sepsis  is  enough 
to  impress  upon  one  the  importance  of  the 
teaching  that  perineal  drainage  should  al- 
ways be  employed  after  internal  urethrotomy 
three  or  more  inches  from  the  meatus. 

When  performing  external  urethrotomy 
without  a  guide  it  is  often  possible  to  trace 
the  continuation  of  the  urethra  proximal  to 
the  opening,  by  means  of  a  filiform  bougie, 
even  when  all  devices  failed  to  secure  the 
introduction  of  a  filiform  before  the  opera- 
tion. If  a  filiform  cannot  be  thus  passed 
through  the  urethral  wound,  suprapubic  pres- 


53 


OENITOURINAKY  TRACT. 


sure  on  the  bladder  may  demonstrate  the  lo- 
cation of  the  urethral  orifice  by  the  escape  of 
a  drop  of  urine  or  by  bulging  of  the  mem- 
branous urethra. 

Avoid  the  temptation  to  employ  a  con- 
strictor upon  the  penis  when  performing  cir- 
cumcision, etc.  It  may  cause  sloughing,  or 
actual  gangrene. 

After  circumcision  it  is  important  to  pre- 
vent adhesion  of  the  reflected  mucous  fold 
of  the  prepuce  to  the  corona  glandis,  by  the 
daily  passage  of  a  probe  about  the  corona, 
and  by  the  use  of  vaselin. 

Absorbent  cotton,  so  commonly  used  to 
catch  the  discharge  of  gonorrhea,  is  very 
inelegant.  It  sticks  to  the  glans,  allows  the 
meatus  to  glue  together,  and  is  difficult  to 
remove  without  soiling  the  fingers.  The  fol- 
lowing is  the  cleanliest  and  most  surgical 
dressing.  In  a  six  inch  square  of  surgical 
gauze,  of  about  four  thicknesses,  cut  a  slit 
in  the  middle  just  large  enough  to  be  passed 
over  the  glans  and  to  be  held  behind  the 
corona.  Then  simply  draw  the  foreskin  for- 
ward.     Indeed,    such   a   dressing   will   hold 


54 


OENITO-URIINAR/  TRACT. 


even  if  the  patient  has  been  circumcised,  if 
the  slit  in  the  gauze  is  not  too  large.  With 
such  a  simple  dressing,  there  is  no  retention 
of  the  pus,  no  irritation  from  contact  with 
the  secretions,  the  organ  is  readily  inspected 
and  the  gauze  is  easily  drawn  off  by  a  little 
pull  at  one  of  its  clean  corners. 

Non-specific  urethral  discharges  in  young 
boys  may  be  due  to  foreign  bodies  introduced 
while  masturbating. 

Examine  the  inguinal  regions  for  hernia  in 
all  cases  of  very  tight  prepuce  causing  diffi- 
culty in  micturition. 

If  difficulty  is  experienced  in  reducing  a 
paraphimosis  because  of  swelling,  before  di- 
viding the  constriction  apply  a  rubber  band- 
age around  the  parts  for  a  few  minutes;  this 
may  reheve  the  swelling  to  such  an  extent 
that  the  paraphimosis  can  be  easily  reduced. 

A    comforting    support    for    the    testicles,      Scrotum 
when  a  patient  is  confined  to  bed  with  or-      and 
chitis,  is  easily  furnished  by  a  well-padded      Testicle. 
cigar   box   cover,    grooved   to   fit   under  the 
scrotum,    and  laid   across   the  thighs.      Ad- 
hesive plaster  may  be  used  in  the  same  man- 
ner. 

55 


OENITO  URINARY  TRACT. 


In  hydrocele  ihe  base  of  the  tumor  is  be- 
low, in  spermatocele  it  is  usually  above.  A 
milky  fluid  obtained  by  aspiration  usually 
speaks  for  spermatocele. 

If  a  cystic  swelling  in  the  scrotum  is 
opaque  when  examined  by  the  well-known 
transillumination  test,  especially  if  a  history 
of  traumatism  is  elicited,  it  may  still  be  a 
hydrocele.  Admixture  of  blood  in  the  hy- 
drocele destroys  its  translucency. 

The  early  reappearance  of  fluid  after  tap- 
ping a  hydrocele  does  not  necessarily  mean 
that  the  operation  has  been  a  failure.  It 
may  be  but  an  inflammatory  reaction,  sub- 
siding spontaneously  or  under  the  applica- 
tion of  unguentum  iodi. 

If  a  male  patient  with  supposed  strangu- 
lated hernia  complains  of  pain  running  down 
the  inner  aspect  of  the  thigh  it  is  well  to 
think  of  torsion  of  the  testicle. 

Accumulated  experience  shows  that  cas- 
tration alone  will  not  cure  the  great  ma- 
jority of  cases  of  tuberculosis  testis.  In 
many,   if  not   most,   cases   the  vas  deferens. 


56 


OENITO-URINARy  TRACT, 


seminal  vesicle  or  prostate  is  involved,  and 
it  will  be  necesasry  to  remove  one  or  more 
of  these  structures  in  order  to  cure.  More- 
over the  other  testicle  frequently  becomes 
tuberculous.     Open-air  therapy  is  helpful. 

Syphilitic  interstitial  orchitis  resembles 
closely  in  appearance  new  growth  of  the 
testicle.  Unless  the  diagnosis  of  neoplasm 
is  beyond  all  doubt,  an  active  course  of 
specific  treatment  should  be  tried  before  re- 
moving the  testicle. 

In  excising  a  varicocele  under  local  anes- 
thesia, tie  the  upper  ligature  first;  the  pain 
of  tying  the  lower  ligature  will  then  be  abol- 
ished. 

After  the  open  operation  for  varicocele 
the  scrotum  may  be  shortened  by  simply  sew- 
ing the  wound  together  transversely  instead 
of  longitudinally. 

The  presence  of  varicocele,  especially  if 
unilateral,  should  suggest  an  examination  of 
the  abdomen  and  pelvis  for  a  possible  growth 
pressing  on  the  spermatic  veins. 


57 


reriALE  oeinerative  organs. 


It  is  a  good  rule  to  always  inspect  the 
labia  before  making  a  vaginal  examination. 
Many  pathological  conditions  in  these  parts 
may  otherwise  pass  unsuspected. 

Don't  be  tempted  to  exclude  gonorrhea 
because  you  see  no  bacterial  or  other  evi- 
dence of  vaginal  or  urethral  infection.  In 
women  the  presence  of  gonorrhea  may  not 
make  itself  known  for  six  weeks  or  more, 
and  salpingitis  may  be  the  first  evidence. 

When  the  openings  of  the  Bartholinian 
glands  appear  as  two  sharply  defined  red 
spots,  an  antedating  inflammation  may  be 
diagnosed  with  certainty,  and  in  a  great  ma- 
jority of  instances  a  latent  gonorrhea  is  pres- 
ent. 

Simple  incision  is  not  sufficient  in  the  treat- 
ment of  Bartholinian  abscesses.  They  should 
be  cauterized  daily  with  iodin,  and  if  they 
recur,  excised. 

Furunculosis  vulvae,  even  when  it  persists 
in  spite  of  all  other  treatment,  will  usually 
yield  to  daily  scrubbing  with  green  soap  and 
the  application  of  a  dressing  of  sublimate 
solution. 


58 


reriALE  generative  oroan5. 


When  cleansing  the  vagina  and  vulva  in 
preparation  for  an  operation,  a  soft  cotton 
mop  should  be  used  for  the  vestibule;  a 
stiff  brush  is  too  apt  to  bruise  or  lacerate 
the  urethra  and  cause  dysuria  for  some  days 
thereafter. 

The  use  of  any  considerable  quantity  of 
iodoformized  gauze  in  the  vagina  involves  the 
risk  of  a  severe  dermatitis  of  the  vulva. 

Before  performing  curettage  always  make 
a  final  bimanual  examination  of  the  uterus 
in  narcosis.  The  finding  may  determine 
some  other  form  of  treatment.  Again,  after 
curettage,  before  allowing  the  patient  to  get 
out  of  bed,  carefully  examine  the  pelvis  for 
signs  of  a  possible  exudate. 

As  a  final  cleansing  step  after  curettage 
of  the  uterus  it  is  well  to  introduce,  and  at 
once  withdraw,  a  packing  of  gauze.  This 
brings  out  with  it  fragments  of  tissue  not 
washed  out  by  the  irrigation. 

Sudden  collapse  after  a  curettage  for  sup- 
posed abortion  may  mean  the  rupture  of  an 
unsuspected  ectopic  gestation  sac. 


59 


TEMALE  GENERATIVE  OROA1N5. 


Carcinoma  of  the  cervix  may  remain  hid- 
den in  the  lumen  of  the  cervical  canal,  w^hich 
is  then  eroded  and  forms  an  irregular  ellipti- 
cal cavity.  While  the  external  os  is  closed 
suspicion  of  the  serious  condition  present  v^ill 
be  attracted  by  ihe  foul  or  bloody  discharge. 

No  operation  for  sterility  in  the  female 
should  be  performed  without  first  excluding 
sterihty  on  the  husband's  part. 

In  case  of  hematocolpos  and  hematometra 
it  is  essential  to  precede  all  interference  by  a 
careful  rectal  examination  in  order  to  de- 
termine whether  the  tubes  are  distended  or 
not.  If  hematosalpinx  exists  a  laporatomy 
and  salpingectomy  must  precede  the  vaginal 
operation,  otherwise  a  severe  peritonitis  may 
be  set  up  by  a  reflex  discharge  of  infective 
secretion  from  the  tubes. 

In  the  early  months  of  pregnancy  exami- 
nations should  be  made  to  determine  that 
there  is  no  retroversion,  or  to  treat  it  if  it 
exists.  A  retroverted  gravid  uterus  impacted 
in  the  curve  of  the  sacrum  always  aborts. 

Ascites  in  the  presence  of  a  mass  in  the 
pelvis  usually,  but  not  necessarily,  means 
malignancy. 

60 


PEMALE  OENERATIVE  OR0AIN5. 


Avoid  introducing  a  uterine  sound  in  ex- 
aminations when  pelvic  inflammation  is  sus- 
pected.    It  may  set  up  a  parametritis. 

Impaction  of  feces  in  the  sigm.oid  and  rec- 
tum, with  absorption  symptoms,  may  simu- 
late pelvic  peritonitis. 

In  pulling  on  the  round  ligaments  in  the 
Alexander  operation,  use  the  fingers  rather 
than  instruments;  a  surer  hold  is  given,  one 
can  gauge  the  proper  force  to  employ  more 
readily,  and  there  is  less  likelihood  of  the 
ligaments  tearing. 

In  all  cases  of  lumbago,  especially  of  the  BACK. 

chronic  variety,  examine  the  sacro-iliac  joints 
for  tenderness.  Such  cases  may  sometimes 
be  almost  instantaneously  relieved  by  apply- 
ing broad  strips  of  plaster  from  beyond  one 
superior  iliac  spine  to  the  other,  across  the 
back.  The  straps  must  be  applied  tightly 
and  with  the  feet  close  together. 

A  skin-lined  sinus  opening  between  the 
coccyx  and  the  anus,  when  not  very  short, 
usually  leads  to  a  dermoid  cyst  situated  close 
to  the  coccyx.  Frequently  loose  hairs  from 
the  dermoid  may  be  found  in  the  sinus. 

6i 


BACK. 


Congenital  paralysis  of  the  lower  limbs 
may  arise  from  an  internal  sacral  or  coccy- 
geal spina  bifida.  In  such  cases  rectal  ex- 
amination reveals  the  trouble  and  an  opera- 
tion may  afford  marked  improvement  or  even 
a  brilliant  cure. 


EATREni- 
TIE5. 


Do  not  consider  too  lightly  a  history  of 
''growing  pains"  in  the  extremities  in  chil- 
dren. These  symptoms  may  be  due  to  a 
grave  osteomyeHtis. 


Do  not  be  in  a  hurry  to  perform  primary 
amputations  after  severe  traumata  of  the  ex- 
tremities. First,  combat  the  shock  and  pre- 
vent hemorrhage.  Keep  the  wound  as  clean 
as  possible;  and  only  when  the  patient  has 
quite  recovered  from  his  shock  (at  the  end 
of  a  few  days  or  more),  perform  the  ampu- 
tation. 


Pulsation  in  the  course  of  an  artery  should 
not  lead  to  the  hasty  conclusion  that  one  is 
dealing  with  an  aneurism.  A  tumor  over- 
lying a  large  vessel,  and  also  a  vascular  sar- 
coma of  the  bone,  may  simulate  an  aneu- 
rism very  closely. 


62 


EATKEniTIE5. 


Never  incise  a  swelling  in  the  course  of  a 
large  artery  without  making  sure  first  that  it 
is  not  an  aneurism. 

When  clamping  a  vein  in  continuity  se- 
cure the  proximal  end  first;  otherwise  it  will 
empty  and  may  become  lost  to  view. 

In  acute  (septic)  osteomyelitis  immediate 
operation  is  not  too  radical;  in  chronic  os- 
teomyelitis patient  waiting  is  often  not  too 
conservative — the  final  expulsion  of  a  seques- 
trum may  be  all  that  is  necessary  to  effect 
spontaneous  cure. 

In  acute,  no  less  than  in  chronic  osteomye- 
litis of  the  long  bones,  an  x-ray  picture  is  of 
immense  service  as  a  guide  in  the  operation. 
It  determines  the  exact  location,  extent  and 
even  character,  of  the  disease  focus,  and  thus 
it  saves  much  unnecessary  destruction  of  bone 
by  the  surgeon's  chisel. 

A  chronic  synovitis  of  apparently  un- 
known origin  and  very  rebellious  to  treat- 
ment is  sometimes  due  to  a  small  focus  of 
osteomyelitis  just  beneath  the  cartilaginous 
surface. 


63 


EATRErilTIE5. 


When  performing  amputation,  arthrec- 
tomy,  osteotomy  or  similar  operation  it  is 
wiser  to  leave  the  constrictor  in  place  until 
the  dressing  is  partly,  or  entirely,  applied, 
than  to  remove  it  after  tying  the  large  ves- 
sels, in  an  effort  to  secure  the  small  ones. 
In  the  former  case  the  snugly  appHed  dress- 
ing w^ill  safely  prevent  hemorrhage;  in  the 
latter  case,  there  may  be  an  alarming  loss 
of  blood  from  the  numerous  small  vessels  in 
the  very  time  the  efforts  are  made  to  tie  them 
all. 

Do  not  amputate  an  extremity  for  sar- 
coma without  a  previous  careful  examina- 
tion of  the  lungs  and  mediastmum  for  me- 
tastasis. Such  symptoms  as  continued  cough, 
a  small  hemoptysis  or  beginning  dyspnea, 
should  be  regarded  as  highly  suggestive  of 
such  a  complication. 

After  major  amputations  an  elastic  con- 
strictor should  always  be  left  at  the  head  of 
the  bed,  so  that  the  nurse  can  immediately 
apply  it  in  case  of  secondary  hemorrhage. 

Never  apply  an  elastic  ligature  about  the 
arm  without  first  interposing  a  towel.  This 
may  obviate  subsequent  paralysis. 


64 


EATREniTIES, 


The  superficial  location  of  the  ulnar  nerve 
must  be  borne  in  mind  when  incising  an  ab- 
scess about  the  inner  aspect  of  the  elbow. 

An  acute  non-purulent  tenosynovitis  may 
be  satisfactorily  treated  by  immobilization 
with  plaster  strips. 

Persistent  pain  in  an  arm  may  be  due  to 
the  presence  of  a  "cervical  rib." 

Persistent  pains  in  the  leg  may  be  due  to 
obliterating  endarteritis.  This  occurs  occa- 
sionally even  in  young  men  and  often  goeo  on 
to  the  production  of  gangrene.  Both  syphil- 
is and  excessive  smoking  are  suspected  as 
etiological  factors. 

Flat-foot  is  another  cause  of  pains  in  the 
leg  or  thigh. 

In  cases  of  pain  in  the  hip  of  doubtful 
origin,  examination  of  the  kidney  regions  may 
discover  the  cause. 

The  presence  of  sciatica  demands  a  care- 
ful exploration  of  the  pelvis  by  rectal  or 
vaginal  examination.     It  should  also  be  re- 


65 


EATRErilTIE5- 


membered  that  Osier  described  sciatica  as 
one  of  the  early  symptoms  of  cancer  of  the 
breast. 

The  following  are  some  of  the  conditions 
in  the  presence  of  which  an  exammation  for 
tabes  dorsalis  should  never  be  omitted :  1 . 
All  primary  swellings  of  the  knee  or  ankle 
joint  without  apparent  origin.  2.  "Sciat- 
ica" and  "lumbago."  3.  A  deep  ulcer  on 
the  base  of  the  great  toe.  4.  Repeated  vomit- 
ing at  various  intervals,  with  periods  of  well- 
being  intervening.  5.  Abdominal  pains 
without  other  evident  cause. 

Pain  in  the  leg  after  an  abdominal  opera- 
tion often  means  the  development  of  a  fe- 
moral vein  thrombosis.  This  occurs  usually 
on  the  left  side. 

Lymph-edema  of  the  lower  extremity  as- 
sociated with  a  swelling  in  the  groin  (fluct- 
uating or  not)  is  significant  of  carcinoma  of 
the  inguinal  glands.  The  primary  lesion  may 
be  in  the  rectum,  e.  g.,  an  epithelioma  of  the 
anus  that  is  giving  no  symptoms. 

When  removing  a  lipoma  or  other  growth 
from  the  inner  surface  of  the  thigh,  a  little 


66 


EATREriITIE5. 


care  should  be  exercised  in  order  to  avoid 
cutting  the  long  saphenous  vein.  Ligature  of 
that  vessel  (especially  in  ambulant  and  in 
non-aseptic  cases)  may  be  followed  by  a  dis- 
tressing phlebitis. 

Inflamed  areas  and  abscesses  about  the 
knees  of  creeping  infants  should  be  exam- 
ined for  foreign  bodies. 

Punctured  wounds  about  the  knee  should 
be  treated  with  the  greatest  solicitude  and 
attention  to  asepsis,  in  order  to  prevent  in- 
fection of  the  joint. 

In  operating  for  loose  bodies  within  the 
knee  joint,  do  not  be  satisfied  with  removing 
but  one  body;  a  careful  examination  should 
be  made  to  determine  the  presence  of  more, 
for  they  are  very  frequently  multiple. 

Do  not  operate  for  foreign  body  in  the 
knee  joint  without  first  excluding  dislocation 
of  one  of  the  semilunar  cartilages. 

In  amputations  below  the  knee,  insist  on 
active  and  passive  motion  in  the  knee  joint 
at  an  early  date.  If  this  is  not  done  con- 
tracture ensues,  which  makes  the  application 
of  an  artificial  limb  difficult. 


67 


EATREriITlE5. 


A  hematoma  may  be  produced  in  the  calf 
muscles  by  direct  or  indirect  violence  that  the 
patient  may  pay  little  attention  to  at  the  time 
or  even  fail  to  recall. 

Swelling  of  the  leg,  associated  with  febrile 
disturbances,  may  be  produced  by  hematog- 
enous infection  of  a  hematoma  of  the  calf 
muscles.  Such  a  condition  may  somewhat 
simulate  osteomyelitis  or  other  serious  con- 
dition. It  may  be  differentiated,  however, 
by  the  location  of  the  greatest  tenderness  and 
swelling  and  by  a  careful  inquiry  into  the 
history.  If  no  distinct  traumatism  is  recalled 
the  condition  of  the  patient's  arteries  may 
nevertheless  suggest  the  possibility  of  the  oc- 
currence of  such  a  hematoma. 

Patients  with  varicose  veins  should  be  in- 
structed that  in  case  hemorrhage  takes  place, 
the  best  method  of  stopping  it  temporarily  is 
to  merely  compress  the  bleeding  point  with 
the  finger. 

Never  advise  an  elastic  stocking  in  cases 
of  varicose  veins  where  recent  phlebitis  exists. 
The  pressure  may  detach  a  part  or  whole  of 
the  thrombus,  propelling  it  into  the  general 
circulation. 


68 


EATREMITIE5. 


Before  anesthetizing  a  patient  to  operate  Hand. 
upon  a  wound  (e.  g.  of  the  wrist),  in  which 
tendons  are  severed,  attach  forceps  or  Hga- 
tures  to  any  tendon  ends  that  are  visible. 
While  strugghng  during  primary  narcosis  the 
proximal  ends  of  cut  tendons  are  sometimes 
drawn  up,  and  the  above  device  will  obviate 
slitting  up  the  sheaths  to  secure  them. 
Squeezing  the  extremity  proximal  to  the 
wound  will  likewise  prevent  these  retractions. 

Never  divide  the  annular  ligament  of  the 
wrist.  The  hand  is  much  weaker  after  it  is 
divided  than  before. 

Frequently  referred  to  the  surgeon  because 
of  the  constant  pain  and  marked  tenderness, 
is  to  be  noted  a  group  of  cases  of  what  might 
be  termed  "occupation  wrist  pain."  They  dif- 
fer from  the  ordinary  case  of  "writer's 
cramp,"  "  piano-player's  cram.p,"  etc.,  in 
that,  while  these  latter  frequently  have  pain 
in,  or  about,  the  wrist,  the  cases  here  re- 
ferred to  have  no  spasm,  the  pain  is  con- 
stant, and  it  is  not  of  a  neuralgic  character. 
Sometimes  it  radiates  along  the  thumb  (as  in 
mail-openers)  ;  sometimes  it  is  localized  to 
the  inner  border  of  the  lower  end  of  the  ulna, 
which   is   very   sensitive   to    pressure    (as   in 


69 


EATRErilTIES. 


shirt-ironers) .  The  fingers  are  free.  There 
may  be  pain  in  the  forearm  muscles  (flex- 
ors). 

For  a  single  tenorrhaphy  make  the  inci- 
sion quite  a  httle  to  one  side  of  the  Hne  of 
the  tendon  and  perform  no  more  dissection 
than  is  necessary.  This  is  to  avoid  adhesions 
of  the  tendon  to  the  skin. 

If  a  tendon  has  been  divided  by  an  in- 
cised or  lacerated  wound  and  the  skin  has 
united  over  it,  it  is  better  to  wait  a  fortnight 
or  more  before  performing  tenorrhaphy. 
Otherwise  organisms  introduced  with  the 
traumatism  may  cause  suppuration  and 
sloughing  of  the  tendon,  not  only  defeating 
the  operation,  but  making  a  later  attempt  at 
approximation  difficult  or  impossible. 

When  exploring  for  a  needle  or  other  for- 
eign body  the  finger  tip  is  often  far  more  use- 
ful than  a  probe  It  must  be  remembered, 
too,  that  strands  of  fascia  often  impart  to  a 
probe  "the  feel"  of  a  foreign  body.  Cut- 
ting and  picking  at  these  deceptive  strands 
of  tissue  soon  distort  the  field  of  operation 
and  destroy  important  relations.  It  is  ex- 
tremely desirable  to  conduct  a  systematic  and 


70 


EATRCniTIE5. 


cleanly    dissection   when   seeking    a    foreign 
body. 

The  best  drainage  should  be  afforded  for 
all  punctured  wounds  of  the  palm;  suppura- 
tions in  this  region  are  very  disagreeable  and 
are  followed  by  severe  consequences. 

The  surgeon  should  not  wait  for  redness 
before  making  a  diagnosis  of  palmar  abscess. 
Owing  to  the  density  of  the  fascial  structures 
this  sign  is  often  lacking  in  the  early  stages. 

In  dealing  with  infections  of  the  hand  bear 
in  mind  that  under  a  simple  bleb  may  lie  an 
extensive  phlegmon,  threatening,  or  actually 
involving,  a  tendon  or  bone  and  urgently 
needing  a  generous  but  wisely  placed  inci- 
sion; while  on  the  other  hand,  a  tendon  may 
be  thrust  from  its  protecting  sheath  into  the 
area  of  destruction  by  a  knife  sweep  more 
earnest  than  judicious.  A  crater-hke  opening 
in  a  sodden  skin,  though  freely  discharging 
pus,  may  need  enlarging  to  protect  the  tissues 
underlying;  while  another  opening,  too  long 
continued  by  unnecessary  packing,  may  crif)- 
ple  a  joint  or  tendon  by  undue  cicatrization. 

In  the  treatment  of  hand  and  finger  in- 
71 


EATREMITIES. 


fections,  it  is  very  important  to  release  from 
bandaging  as  much  and  as  many  of  the  fin- 
gers as  possible,  and  as  soon  as  possible.  The 
habit  of  bandaging  up  immovably  all  the 
fingers,  in  the  treatment  of  a  lesion  of  some 
of  them,  saves  the  surgeon  time  but,  except 
in  short  cases,  it  often  cripples  the  hand  by 
stiffening  the   fingers. 

Occasionally,  contractures  of  the  fingers 
following  the  treatment  of  a  cellulitis  of  the 
hand  and  forearm  may  be  due,  not  to  the 
cellulitis  itself  nor  to  the  incisions  made  to 
relieve  it,  but  to  fibrosis  and  shortening  of 
the  flexors  in  the  forearm,  the  result  of  too 
tight  bandaging  or  strapping.  Such  a  con- 
dition— Volkmann's  ischemic  muscle  contrac- 
ture— must,  therefore,  be  distinguished  from 
the  stiff,  flexed  fingers  produced  by  the  cellu- 
litis. Passive  motions  and  massage  are  help- 
ful in  both  conditions,  but  in  the  former  bone 
shortening  (radius  and  ulna)  is  necessary 
to  accommodate  the  contractured  muscles. 


Remember  that  chronic  ulcers  on  the 
hands  are  found  in  brass  workers,  and  that 
a  discontinuance  of  this  occupation  is  neces- 
sary to  secure  healing. 


72 


EATKEniTIE5. 


Indolent  sinuses,  as  of  the  fingers  after 
deep  infections,  frequently  heal  by  the  daily 
use  of  prolonged  immersions  in  hot  water. 

In  dealing  with  infections  or  injuries  of 
the  fingers  amputation  should  be  a  last 
resort.  This  is  especially  the  case  with  a 
thumb,  the  most  important  of  all  the  fingers. 

In  a  case  of  fresh  traumatic  amputation 
of  a  part  of  the  finger,  if  the  amputated  part 
has  not  been  too  lacerated  or  crushed,  try 
to  restore  the  member  by  cleansing  the  parts 
carefully  and  suturing  it  to  the  stump.  Once 
in  a  while  the  graft  will  "take." 

Amputation  of  a  finger  gangrenous  as  the 
result  of  carbolic  acid  application  should  not 
be  performed  until  the  line  of  demarkation  is 
well  established.  The  necrosis  may  be  su- 
perficial and  in  such  an  instance  the  finger 
may  be  saved  by  means  of  skin  graft. 

Tenderness  in  the  heel,  or  pain  and  ten-       Toot. 
derness  in  the  sole  of  the  foot  is  very  often, 
indeed,  of  gonorrheal  origin.     It  will  not  be 
relieved  in  such  cases  until  treated  on  that 
basis.     The  patient  may  deny  that  he  ever 


73 


EATREniTIES. 


had  gonorrhea.     Examine  his  urine;  shreds 
tell   their  own  story. 

Do  not  be  too  hasty  in  ascribing  the 
cause  of  pain  in  the  tendo  Achilles,  or 
Achilles  bursa,  to  an  ill-fitting  shoe.  First 
exclude  gonorrheal  infection. 

If  the  cause  of  pain  in  the  feet  is  not  other- 
wise clear,  examine  them  in  the  dependent 
position.  This  may  develop  the  presence  of 
erythromelalgia. 

The  determination  of  the  presence  of  a 
fracture  of  one  of  the  mid-tarsal  bones  is 
extremely  difficult,  and  usually  impossible, 
without  x-ray  examinations.  Yet  these  ex- 
aminations have  shown  the  occurrence  of 
such  fractures,  alone,  or  associated  with  in- 
juries to  other  bones,  as  the  result  of  injuries 
by  slight  or  severe  direct  violence.  For 
this  reason,  and  because  fractures  of  the 
metatarsals  by  indirect  violence  are  by  no 
means  uncommon,  it  should  be  practically 
a  routine  to  submit  the  foot  to  skilful  skiag- 
raphy in  all  cases  where  either  form  of  vio- 
lence may  have  occurred.  It  will  save  many 
patients   from  weeks   of  suffering   and   disa- 


74 


EATREniTIES. 


bility.  In  this  region,  more  than  in  any 
other,  the  x-rays  are  a  means  of  diagnosis 
that  cannot  be  dispensed  with. 

Many,  at  least,  of  the  sprains  of  the  an- 
kle involve  a  fracture  of  the  tip  of  the  mal- 
leolus, and  should  be  treated  by  immobili- 
zation in  plaster-of-Paris. 

In  old  people,  as  in  diabetics,  corns, 
bunions  and  wounds  of  the  feet  demand  the 
most  careful  attention.  They  are  often  the 
starting  points  of  gangrene. 

A  very  simple  method  of  curing  a  corn  is 
to  excise  it. 

In  ingrowing  toenail,  evulsion  of  the  nail 
gives  temporary  rehef,  but  it  does  not  cure. 
When  the  nail  grows  out  again  the  condition 
recurs,  often  in  aggravated  form. 

It  is  doubtful  whether  the  classical  opera- 
tions for  ingrown  toe-nail  cure  permanently 
in  even  a  fair  percentage  of  cases.  Conser- 
vative treatment  will  usually  accomplish  as 
much,  even  in  the  presence  of  granulating 
masses.     Tliis  treatment  includes  drawing  the 


75 


EATRErilTIE5. 


flesh  away  from  the  nail  with  a  strip  of  ad- 
hesive plaster,  insertion  of  a  gauze  packing 
under  the  nail  edge  and  the  appHcation  of  an 
absorbent  antiseptic  dressing. 

Be  very  guarded  in  the  prognosis  of  ul- 
cerations on  the  sole  of  the  foot  in  diabetic 
or  tabetic  patients,  no  matter  how  small  or 
trifling  the  ulceration  may  be.  They  persist 
for  long  periods  and  may  even  never  heal. 


TKAC- 
TURE5. 


Very  often  the  unskillful  treatment  of  a 
fracture  is  worse  than  no  treatment  at  all. 
Serious  deformities  may  result  from  the  neg- 
lect of  small  details  no  less  than  from  the 
violation  of  important  principles. 


The  important  considerations  in  the  treat- 
ment of  fractures  are,  at  first,  relief  of  pam 
and  reduction  of  swelling,  and,  subsequently, 
preservation  of  function  of  the  muscles,  the 
nerves  and  the  neighboring  joints.  Hence 
the  value  of  early  and  frequent  massage  and 
passive  motion  (and  in  suitable  cases,  of 
active  motion)  and  the  necessity  for  avoid- 
ing splints  that  unduly  compress  the  muscles 
or  deprive  them  of  activity. 


76 


PRACTURE5. 


In  the  treatmenl  of  fractures  of  the  fore- 
arm no  consideration  is  more  important  than 
the  avoidance  of  contractures  of  the  fingers, 
by  the  intelligent  use  of  splints  and  by  means 
of  early,  active  and  passive  movements. 

Permanent  contracture  of  the  muscles,  not- 
ably of  the  flexor  group  in  the  forearm,  may 
develop  within  a  very  short  time  after  the 
application  of  a  splint  that  exercises  undue 
compression.  It  is  a  wise  rule  to  inspect  all 
fracture  dressings  within  twenty-four  hours; 
and  when  this  is  not  expedient  special  care 
should  be  exercised,  when  applying  the  dress- 
ing, to  avoid  compression. 

In  very  many  cases  it  is  not  necessary  to 
the  diagnosis  of  fracture  to  ehcit  crepitus 
and  abnormal  mobility — often  painful  man- 
ipulations. In  several  forms  of  fracture 
there  are  other  positive  diagnostic  evidences. 
Thus,  with  CoUes'  fracture  the  level  of  the 
styloid  of  the  radius  will  almost  always  be 
found  to  have  receded  from  beyond  that  of 
the  styloid  of  the  ulna.  Moreover,  x-ray 
examinations  save  much  painful  manipula- 
tion. 

After  all,  the  localization  of  bone  tender- 

77 


TKACTURES. 


ness  is  not  only  the  most  useful  sign  in  de- 
termining the  site  of  a  fracture,  but,  even  in 
the  absence  of  other  signs,  it  is  often,  in 
itself,  diagnostic  of  the  presence  of  a  frac- 
ture. As  instances  may  be  cited  greenstick 
fracture  of  the  clavicle,  and  fracture  of  the 
metacarpal  and  metatarsal  bones. 

In  all  examinations  of  children,  and  in  the 
examination  of  adults  for  suspected  fractures, 
leave  the  painful  manipulations  for  the  last. 

The  x-rays  have  taught  us  that  mathemati- 
cal reduction  is  rarely,  and  even  linear  re- 
duction is  seldom,  accomplished  even  in 
cases  in  which  excellent  functional  results 
are  secured.  Radiographs  have  thus  fre- 
quently been  made  the  basis  of  blackmail- 
ing damage  suits.  Nevertheless,  the  x-rays 
are,  of  course,  of  immense  value  in  the  treat- 
ment of  fractures — not  only  for  reference 
before  and  after  reduction,  but  during  the 
reduction  itself. 

A  fracture  produced  by  only  slight  vio- 
lence should  at  once  raise  the  suspicion  of 
a  malignant  growth.  In  such  a  case  a  uni- 
form dark  shadow  about  the  bone  as  seen 


78 


rRACTURE5. 


in  the  fluoroscopc  is  to  be  interpreted  as  a 
neoplasm  rather  than  as  callus,  for  recent 
callus  is  not  opaque  to  the  x-rays. 

That  a  bone  appears  normal  by  fluoro- 
scopic examination  does  not  gainsay  the  pres- 
ence of  a  fracture.  A  fracture  of  the  radius, 
for  example,  may  occur  without  displacement 
of  the  fragments.  An  x-ray  plate  will  dem- 
onstrate the  line  of  fracture,  when  the  fluoro- 
scope  fails  to. 

Severe  localized  pain  after  traumatism,  es- 
pecially in  children,  may  be  due  to  sub- 
periosteal fracture,  e.  g.,  near  the  head  of 
the  humerus  or  the  femur.  Extreme  local- 
ized tenderness  is  the  chief  sign;  abnormal 
mobility  and  deformity  are  absent,  and  crepi- 
tus may  not  be  elicited. 

In  cases  of  fracture  where  an  end  of  the 
bone  lies  close  beneath  the  skin  do  not  place 
a  pad  or  any  pressure  whatever  over  this 
point. 

In  compound  fractures  involving  loss  of 
continuity  do  not  needlessly  remove  any  piece 
of  bone  that  has  even  the  smallest  attachment. 


79 


PRACTURE5. 


It  is  surprising  how  often  such  pieces  heal 
into  the  wound  and  thereby  help  to  save  loss 
of  substance. 

When  applying  a  plaster  dressing  to  the 
leg  always  include  the  foot  if  the  patient  is 
to  be  confined  to  bed;  otherwise  "drop  foot** 
will  develop. 

In  cases  of  fracture  of  a  rib,  it  is  neces- 
sary to  watch  the  patient  carefully  for  a 
couple  of  days  to  note  the  onset  of  a  possible 
lung  compHcation.  Locahzed  pneumonitis 
sometimes  occurs. 

In  severe  falls  or  blows  or  fractures  of 
the  pelvis,  catheterize  the  patient  as  soon 
after  the  injury  as  possible  in  order  to  dis- 
cover a  possible  rupture  of  the  bladder. 


Fracture  of  the  outer  end  of  the  clavicle 
may  follow  a  fall  upon  the  shoulder.  Un- 
less one  makes  a  careful  examination  such  a 
fracture  may  escape  observation  or  be  mis- 
taken for  a  dislocation  of  the  outer  end  of 
the  clavicle,  with  which  condition,  indeed, 
it  may  be  associated. 


80 


FRACTURES. 


Shortening  of  the  shoulder,  as  measured 
from  the  sternal  end  of  the  clavicle  to  the 
acromion  process,  is  significant  of  fracture 
of  the   clavicle. 

In  the  aged,  pain  and  disability  in  the  arm 
after  traumatism  demand  especial  care  in 
examination  of  the  shoulder.  Fracture  of 
the  head  of  the  humerus  is  often  overlooked. 

In  fractures  of  the  anatomical  neck  of  the 
humerus,  examine  carefully  for  injuries  to 
the  brachial  plexus. 

The  radiograph  of  the  elbow  of  a  child 
shows  shadows  of  numerous  epiphyses.  One 
inexperienced  with  x-ray  plates  is  very  apt  to 
mistake  one  or  more  of  these  for  fractures. 
When  examining  the  skiagraph  of  a  child's 
elbow  suspected  of  fracture  or  dislocation, 
it  is,  therefore,  important  to  have  the  normal 
picture  in  mind,  or  better  yet  in  hand,  for 
comparison. 

Fractures  of  the  head  of  the  radius  are 
probably  more  common  than  generally  sup- 
posed, being  overlooked  frequently  because 
of  the  absence  of  the  ordinary  signs  of  frac- 
ture. 

81 


rRACTURE5. 


If  a  small  child  has  been  pulled  by  the 
arm  and  thereafter  has  disability  in  that 
member,  attention  should  first  be  directed  to 
the  upper  end  of  the  radius.  Here  one  is 
apt  to  find  a  subluxation  of  the  head  of  the 
bone  ("pulled  arm")  or  an  epiphyseal  sepa- 
ration. 

Marked  tenderness  over  the  lower  end  of 
the  radius,  after  traumatism,  without  deform- 
ity, is  suspicious  of  fissure  of  the  bone.  Mo- 
bility or  crepitus  may  be  obtainable. 

The  silver-fork  deformity  is  by  no  means 
necessary  to  the  diagnosis  of  Colles'  frac- 
ture. 

If  a  patient  gives  a  history  of  "sprained 
wrist"  that  has  remained  feeble  and  pain- 
ful in  spite  of  appropriate  treatment  for  suffi- 
cient time,  and  if  the  wrist  presents  thick- 
ening and  tenderness  at  its  radial  aspect,  a 
diagnosis  of  fracture  of  the  scaphoid  should 
be  entertained.  Colles'  fracture  must  be  ex- 
cluded, by  the  relation  of  the  two  styloid  pro- 
cesses and  the  location  of  the  deformity. 
Fractures  of  the  radius  and  scaphoid  may, 
however,  coexist. 


82 


rRACTUKE5. 


Fractures  of  ihe  neck  of  the  femur  in  old 
people  sometimes  cause  no  other  symptoms 
than  disability.  The  mildness  of  the  trauma 
and  the  freedom  from  much  pain  should  not 
deceive  one. 

A  padded  triangular  wooden  or  card- 
board splint — one  leg  of  the  triangle  band- 
aged to  the  thigh,  and  another  to  the  trunk 
— makes  an  excellent  ambulatory  apparatus 
in  the  treatment  of  fractures  of  the  shaft  of 
the  femur  in  small  children.  It  maintains 
reduction,  leaves  the  leg  free  and  does  not 
interfere  with  keeping  the  child  clean. 

Cardboard  sphnts  can  be  best  molded  to 
an  extremity  by  tearing,  instead  of  cutting 
them. 

In  operations  for  suture  of  a  fractured  pa- 
tella it  is  very  important  to  sew  the  torn 
lateral  ligaments  of  the  joint.  These  aid 
largely   in  the  support  of  the  joint. 

It  must  be  remembered  that  fractures  of 
the  metatarsal  bones  may  be  produced  by 
slight  injuries.  Thus,  the  base  of  the  fifth 
metatarsal  may  be  fractured  by  a  twist  of 
the  foot  while  walking  or  dancing. 


83 


LyriPHATIC  0LAND5. 


An  accurate  knowledge  of  the  lymphatic 
drainage  of  the  various  regions  of  the  body  is 
absolutely  necessary  before  one  can  deter- 
mine the  origin  of  a  glandular  infection.  This 
is  especially  important  in  cancer,  when  some- 
times the  glandular  involvement  offers  the  first 
clue  to  the  primary  focus. 

Do  not  advise  extirpation  of  large  glands 
in  any  particular  region  without  making  sure 
that  they  are  not  the  early  manifestations  of 
leukemia  or  Hodgkin's  disease. 

If  a  bubo  shows  no  sign  of  disappearing 
under  wet  dressings,  ice  bags,  etc.,  and  evi- 
dences of  suppuration  are  developing,  it  is 
better  to  make  a  clean  dissection  and  excise 
the  gland  without  opening  it  than  to  incise 
and  drain. 

^■^'^  Exposure  to  the  x-rays  causes  atrophy  of 

the  sweat  glands;  radiotherapy  is  proving 
the  most  satisfactory  treatment  for  hyperi- 
drosis. 

Pure  nitric  acid,  applied  on  the  narrow, 
blunt  tip  of  a  glass  rod  is  successful  in  the 
complete  destruction  of  verruccae,  but  only 
if  it  is  forced  down  into  their  very  roots. 

84 


5KIN. 


Localized,  indurated  or  softening  skin  in- 
fections ("boils")  often  disappear  com- 
pletely or  open  painlessly  under  an  applica- 
tion of  emplastrum  plumbi  in  which  is  in- 
corporated 10  per  cent,  of  salicylic  acid;  or 
of  10  per  cent,  to  20  per  cent,  salicylated 
soap  plaster.  After  the  boil  opens  the  tiny 
dressing  should  be  changed  every  two  or 
three  hours. 

When  shaving  the  hair  in  the  neighbor- 
hood of  a  boil,  draw  the  razor  from  the  base 
to  the  apex  so  as  not  to  drive  microorganisms 
deeper  into  the  tissues. 

Do  not  treat  locaHzed  subcutaneous  red 
and  tender  swellings  as  infections  without 
first  making  sure  that  they  are  not  evidences 
of  gout. 

Stains  of  anilin  dyes  may  be  removed 
from  the  fingers  with  strong  hydrochloric 
acid,  stains  of  iodin  with  aqua  ammonia, 
and  stains  by  silver  nitrate  with  potassium 
iodid  solution. 


If  an  incised  wound  in  the  soft  parts  does 
not  heal  as  readily  as  it  should,  examine  the 
urine  for  sugar. 

85 


VOUIND5. 


WOUNDS. 


In  wounds  made  by  coal  on  the  exposed 
parts  of  the  body,  remove  all  the  particles 
of  coal  dust;  otherwise  a  disfiguring  pig- 
mentation might  follow. 

A  broad  clean  ulcer  on  the  soft  parts 
often  heals  per  primam  if  its  surface  is 
swabbed  with  iodin  and  its  edges  then 
brought  together  with  adhesive  straps. 

An  ulcer  with  indolent  flabby  granula- 
tions may  be  stimulated  to  renewed  activity 
by  a  thorough  scraping  or  by  vigorously 
rubbing  it  with  gauze. 

Catgut  strands  do  not  always  make  a 
good  drain  for  wounds;  they  tend  to  swell 
and  occlude. 

Fresh  wounds  about  a  joint  should  not  be 
probed  to  see  whether  the  joint  has  been 
penetrated  or  not.  This  is  an  excellent  way 
of  infecting  it. 

The  appearance  of  emphysema  in  the  tis- 
sues about  an  infected  wound,  accompanied 
by  fever  and  escape  of  bubbles  of  gas  from 
the  wound,  should  be  regarded  as  very  omi- 


86 


WOUND5. 


nous,  and  indicative  of  gas  bacillus  infec- 
tion. Such  cases  should  be  treated  by  ex- 
tensive incisions. 

Blank  cartridge  wounds  must  be  laid  wide 
open,  all  dirt  and  wad  carefully  removed, 
and  the  area  swabbed  out  with  tincture  of 
iodin,  or  with  pure  carbolic  acid  followed  by 
alcohol.  Tetanus  antitoxin  should  be  ad- 
ministered. 

If  the  powder  grains  are  not  promptly  re- 
moved in  gunshot  wounds  of  the  exposed 
part,  unsightly  discolorations  result. 

The  possible  development  of  a  duodenal 
ulcer  in  cases  of  extensive  burns,  must  always 
be  borne  in  mind. 

Too  prolonged  or  too  rapid  and  vigorous 
use  of  the  pump  in  the  Bier  apparatus  will 
frequently  cause  a  rupture  of  the  superficial 
bloodvessels,  and  in  many  cases  severe 
sloughing  of  the  superficial  parts  ensues,  the 
result  of  the  treatment  being  worse  than  the 
primary  cause  of  the  trouble.  Application 
of  the  Bier  cup  to  an  abscess  for  four  to 
five  minutes  twice  a  day  is  more  beneficial 
than  a  single  ten-minute  application. 


87 


TUnORS. 


Soft  tumors  under  the  skin,  disappearing 
in  the  recumbent  posture,  are  usually  lym- 
phangiomata. 

If  a  sweUing  is  ''fluctuating"  do  not  be 
too  sure  that  it  is  not  a  solid  growth.  Lym- 
phangiomata  fluctuate. 

A  subcutaneous  tumor  with  a  history  of 
puncture  or  the  presence  of  a  minute  scar 
in  the  overlying  skin,  usually  means  that  one 
is  dealing  with  an  inclusion  or  so-called 
Ranvier  cyst. 

In  hard  swellings  of  doubtful  nature 
marked  tenderness  is  significant  of  actinomy- 
cosis, when  acute  inflammation  may  be  ex- 
cluded. 

Do  not  give  a  good  prognosis  in  cases  of 
melanosarcoma  of  the  fingers  or  toes,  no 
matter  how  small  the  tumor  may  be,  and  no 
matter  how  high  the  amputation  is  performed. 
In  the  majority  of  cases,  these  patients  suc- 
cumb to  metastases. 

In  the  presence  of  a  pulsating  tumor,  es- 
pecially of  the  bone,  examine  the  kidneys. 
Secondary  hypernephromata  always  pulsate. 


88 


TUnORS. 


A  pulsating  tumor  of  the  os  ilium  (en- 
dothelioma, sarcoma)  may  easily  be  mistaken 
for  a  gluteal  aneurism. 

The  **egg  shell  crackle"  of  certain  bone 
tumors  is  characteristic  of  multiple  myeloma. 
Examine  the  urine  for  albumose. 

In  cases  of  bone  tumor  these  organs  should 
never  be  overlooked  in  seeking  a  primary 
growth — the  prostate  or  mammary  glands, 
according  to  the  sex,  and  the  thyroid. 

An  amputation  for  malignant  ulceration 
should  not  be  performed  until  the  possibility 
of  its  being  merely  a  broken-down  gumma 
has  been  satisfactorily  excluded. 

A  metastatic  growth  in  a  superficial  lym- 
phatic gland  or  a  gland  of  the  skin  may 
sometimes  deceptively  simulate  the  appear- 
ance of  a  sebaceous  cyst.  In  a  patient  suf- 
fering with  a  malignant  neoplasm,  therefore, 
the  development  of  a  "wen,"  especially  if 
at  an  unusual  situation,  should  be  regarded 
with  sufficient  suspicion  to  prompt  investiga- 
tion of  its  interior. 

Individuals    with    bluish    sclerotics,    and 

89 


TUBER- 
CULOSIS. 


TUBERCUL05I5. 


with  dark  lanugo  over  the  upper  part  of  the 
back,  are  usually  of  tuberculous  diathesis; 
and  these  signs  are  not  inconsequential  in 
maknig  a  diagnosis. 

Surgical  tuberculosis,  no  less  than  pul- 
monary tuberculosis,  calls  for  the  most  care- 
ful general  treatment,  post-operative  and 
otherwise.  Out-of-door  life  is  as  important 
here  as  for  phthisis. 

The  temptation  should  not  be  yielded  to 
to  incise  a  psoas,  hip  or  other  "cold"  ab- 
scess, except  in  isolated  instances  and  then 
only  under  the  most  rigid  asepsis.  The  pro- 
duction of  a  mixed  infection  means  chronic 
sinus,  chronic  invalidism  and,  often,  amy- 
loid disease. 

AINE3-  ^"  operations  upon  the  head  or  neck  the 

TMFSIA  anesthetist  must  see  to  it  that  no  instrument 

is  allowed  to  lie  over  the  cornea,  especially  if 

it   is   exposed.      Ulceration   may   be   caused 

with  ease ;  it  is  often  healed  with  difficulty. 

During  narcosis,  when  stertorous  breath- 
ing calls  for  extension  of  the  jaw,  it  is  well 
to  hold  it  forward  first  on  one  side,  then  on 


90 


ANE5THE5IA. 


the  other,  alternating  at  short  intervals.  Long 
continued  pressure  at  the  angle  or  angles  of 
the  jaw  produces  much  soreness.  Often  the 
jaw  can  be  kept  forward  by  catching  the 
lower  incisor  teeth  in  front  of  the  upper  ones 
(if  they  are  strong)  ;  a  single  finger  on  the 
chin  is  enough  to  maintain  this  position. 

In  hght  narcosis  the  pupils  may  dilate 
reflexly  from  operative  manipulations.  This, 
of  course,  is  not  to  be  confused  with  the 
sudden  extreme  dilatation  that  occurs  when 
the   narcosis   has    been   carried   too   far. 

During  the  conduct  of  a  narcosis,  more 
important  than  the  activity  of  the  conjuncti- 
val reflex  or  the  actual  size  of  the  pupil  in 
determining  the  depth  of  the  anesthesia,  are 
the  changes  in  the  reactibility  of  the  lid  and 
the  alterations  in  the  size  of  the  pupil.  They 
are  reHable  indices  to  fluctuations  in  the  depth 
of  the  narcosis.  Sometimes  a  patient  is  quite 
relaxed  and  anesthetic  although  a  fair  con- 
junctival reflex  is  present;  and,  again,  it  may 
occasionally  happen  that  a  patient  reacts 
even  when  that  reflex  is  abolished. 

In  crying  infants  it  is  extremely  difficult  to 
determine  the  presence,  and  location,  of  ten- 


91 


ANE5THE5IA. 


der  areas.  This  may  be  readily  accom- 
plished by  the  administration  of  chloroform 
to  the  extent  of  primary  narcosis.  The  phy- 
sical examination  then  becomes  very  easy 
and  when  a  tender  spot  is  handled  it  will  be 
announced  at  once  by  lively  reflexes. 

During  the  performance  of  a  hernia  op- 
eration it  is  often  helpful  for  the  anesthetist 
to  allow  the  patient  to  react  sufficiently  to 
strain  into  view  a  sac  that  has  slipped  back 
into  the  abdomen. 

A  convenient  way  in  which  the  anesthetist 
may  carry,  all  sterilized  and  ready  for  in- 
stant use,  his  hypodermatic  solutions,  is  the 
following:  Shallow,  wide-mouthed,  half- 
ounce  bottles  are  sterilized,  labeled  and  filled. 
Over  the  mouth  of  each  bottle  is  then 
stretched,  and  hermetically  fastened,  a  cover 
of  sterilized  rubber  (dam).  Before  the 
narcosis  is  begun  the  anesthetist  disinfects  his 
syringe  and  sets  these  bottles  in  a  dish  of 
sublimate  solution.  This  sterilizes  the  sur- 
face of  the  rubber.  When  a  solution  is 
wanted  the  needle  of  the  hypodermatic 
syringe  is  simply  thrust  through  the  rubber  and 
as  much  as  is  needed  is  drawn  into  the  bar- 
rel.    The  puncture  hole  closes  without  leak- 


92 


ANE5TME5IA. 


age.     The  covers  of  the  bottles  need  to  be 
changed  only  occasionally. 

Whenever  the  arrangement  of  a  patient 
upon  the  operating  table  requires  an  extrem- 
ity to  occupy  a  constrained  position,  that  po- 
sition should  be  shifted  from  time  to  time 
to  avoid  pressure  paralysis.  The  anesthetist 
should  never  draw  the  arms  alongside  the 
head,  nor  permit  the  strap  of  a  leg-holder 
to  press,  for  more  than  a  few  minutes  at  a 
time,   upon  the  brachial  plexus  in  the  neck. 

Nitrous  oxid  narcosis  can,  in  most  cases, 
be  continued  "smoothly,"  with  no  cyanosis 
and  with  fair  degree  of  relaxation,  even  for 
an  hour.  A  laparotomy  may  thus  be  per- 
formed, if  ether  and  chloroform  are  contrain- 
dicated.  To  secure  such  a  narcosis  it  is  best 
to  use  an  apparatus  that  permits  exhalation 
into  the  gas  bag,  and  which  has  a  valve  for 
the  admission  of  air.  The  bag  should  not  be 
distended  fully.  After  brief  air  and  gas 
administrations,  air  is  turned  off  and  the  pa- 
tient breathes  N-O  and  his  own  CO;.  At 
short  intervals,  and  whenever  there  is  any 
cyanosis,  a  single  breath  of  pure  air  is  al- 
Io^ved. 


ANE5THE5IA. 


Local  anesthetics  cannot  be  injected  pain- 
lessly into  tense,  inflamed  areas  unless  the  in- 
jection is  begun  at  a  point  in  the  skin  well 
beyond  the  seat  of  inflammation. 

The  admixture  of  adrenahn  to  cocain  so- 
lution counteracts  much  of  the  depressant 
effect  of  the  anesthetic  and  enhances  the 
local  vaso-constriction.  When  the  mixture 
is  used  on  the  surface  of  a  mucous  mem- 
brane, however,  as  in  excising  an  ulcer  in 
the  mouth,  one  must  be  prepared  for  a 
marked  reactionary  bleeding. 

INPU5ION5.  ^^^   ^   single   intravenous   infusion,   as    to 

combat  the  shock  of  hemorrhage,  it  is  not 
essential  that  the  solution  contain  any  of  the 
blood  salts  but  the  most  abundant  one — 
sodium  chlorid.  For  repeated  infusions, 
however,  as  sometimes  used  in  treating  vari- 
ous toxemias,  it  is  better  to  employ  also  the 
other  salts,  the  solution  being  made  of  so- 
dium chlorid  0.9,  potassium  chlorid  0.03, 
calcium  chlorid  0.02,  water  100. 

Intravenous  saHne  infusions  in  too  large 
volume  are  harmful  by  the  production  of  con- 
gestion of  the  internal  viscera.     One  to  one 


94 


IPSPU5ION5. 


and  a  half  pints  is  enough  for  an  adult  of 
average  weight. 

In  performing  subcutaneous  infusion  do 
not  allow  too  much  fluid  to  accumulate  at 
one  area,  otherwise  necrosis  may  occur.  Shift 
the  needle  to  various  parts  not  by  swinging 
it  from  side  to  side,  but  by  partly  withdraw- 
ing it  and  reinserting  it  to  another  area. 

The  pain  in  the  lower  part  of  the  back      P05T= 
that  is  so  frequently  complained  of  after  op-      OPERATIVE. 
eration,   can   be   best   reheved  by  placing   a 
small  pillow  in  the  hollow  of  the  spine. 

In  determining  the  cause  of  a  post-opera- 
tive  fever  never   fail  to  look   at  the  throat. 

If,  after  a  period  of  post-operative  cathe- 
terization, the  patient  finds  herself  unable  to 
pass  urme  spontaneously,  apply  hot  towels 
to  the  vulva. 

Gastric  lavage  is  the  best  post-operative 
anti-emetic. 

Vomiting  may  frequently  be  controlled 
by  one-drop  doses  of  tincture  of  iodin  in 
water  at  half-hourly  intervals. 


95 


POST-OPERATIVE. 


Before  putting  an  unconscious  patient  to 
bed,  the  hot  water  bags  should  be  removed  or 
sufficiently  covered  to  prevent  the  occurrence 
of  a  burn. 

The  occurrence  of  post-operative  phlebitis 
is  often  encouraged  by  keeping  the  patient  too 
long  in  bed. 

Old  people  should  be  allowed  to  sit  up  or 
get  out  of  bed  as  soon  after  operation  as 
possible  in  order  to  avoid  post-operative  lung 
complications. 


HEnOR- 
PHAOE  AND 
5MOCK. 


Do  not  allow  patients  to  lie  on  the  back 
immediately  after  an  operation  involving  the 
vertebrae  or  the  sacrum;  a  disagreeable  ne- 
crosis of  the  skin  flaps  may  rapidly  take 
place. 

In  differentiating  shock  and  concealed 
hemorrhage  progressiveness  of  the  symptoms 
is  very  significant  of  continued  bleeding. 

Restlessness,  increasing  pallor,  increasing 
air-hunger,  increasing  weakness  of  the  pulse, 
falling  temperature  (subnormal),  and  the 
ephemeral  effect  of  stimulation,  all  point  to 


96 


HEnORRMAOE  AND  5MOCK. 


hemorrhage  rather  than  shock.      In  addition, 
there  is  often  some  local  sign  or  symptom. 

In  post-operative  collapse  if,  after  study- 
ing the  symptoms,  there  be  any  doubt  wheth- 
er the  condition  be  due  to  shock  or  to  con- 
cealed hemorrhage,  the  wound  should  be 
opened  and  bleeding  sought  for. 

In  dealing  with  secondary  hemorrhage 
from  the  rectum  (whether  bleeding  vessels  are 
tied  or  not),  it  is  better  to  tampon  with  gauze 
wrapped  about  a  piece  of  stout  rubber  tub- 
ing, than  with  gauze  alone. 


Bone  tenderness,  especially  of  the  sternum 
and  tibiae,  is  frequently  significant  of  sepsis. 


5EP5I5. 


In  seeking  the  source  of  an  obscure  sepsis, 
do  not  overlook  an  examination  of  the  is- 
chiorectal region. 


Aluminum  instruments  should  not  be 
boiled  in  soda  solution  like  other  instru- 
ments. They  are  to  be  sterilized  by  boiling 
in  plain  water  or  by  passing  them  through  an 
alcohol  or  Bunsen  flame. 


IN5TRU. 
riENT5. 


97 


IN5TRUnEINT5. 


Woven  catheters  may  be  sterilized  by 
boiling  in  saturated  ammonium  sulphate  solu- 
tion. Catheters  and  bougies  may  be  kept 
aseptic  if  they  are  wrapped  in  gauze  wet 
with  the  soap-spirits  of  the  German  pharma- 
copeia. 

Warming  a  laryngeal  mirror  prevents  con- 
densation of  the  breath  upon  it  for  only  a 
short  time.  The  mirror  will  remain  bright, 
however,  throughout  a  prolonged  examina- 
tion if,  instead  of  warming  it,  its  surface  iS 
smeared  with  an  invisible  film  of  soap. 

An  "invalid  table,"  the  shelf  of  whicki 
projects  over  the  patient's  body,  will  be 
found  a  great  convenience  during  operations 
as  a  receptacle  for  instruments  in  immediate 
use.  It  saves  time  and  temper,  and  avoids 
accumulation  of  instruments  on  the  patient's 
body. 

When  scissors  become  "catchy"  their 
edges  can  often  be  surprisingly  smoothed  by 
carrying  each  blade  repeatedly  from  lock  to 
tip  between  the  firmly  pressing  thumb  and 
forefinger.  Each  kind  and  size  of  scissors 
has  its   own  capacity,   and   should  be  used 


98 


lN5TRUnENT5. 


only  for  what  it  is  intended.  Ophthalmic  in- 
struments are  not  intended  for  ordinary  dis- 
sections, tissue  scissors  should  not  be  used  for 
cutting  bandages,  nor  bandage  scissors  for 
plaster-of-Paris. 

Bandage  knives  cut  best  when  they  have 
a  "saw  edge,"  which  is  easily  secured  by 
sharpening  them  on  a  window  sill  or  other 
rough  stone. 

A  scroll-saw,  with  an  assortment  of  a 
dozen  saws,  can  be  purchased  at  the  hard- 
ware store  for  twenty-five  cents;  it  is  ideal 
for  resection  of  the  small  bones  of  the  hand 
and  foot,  for  amputations  of  the  digits,  etc. 

Well  tempered  carpenter's  chisels  and 
gouges,  and  a  carpenter's  wooden  mallet 
answer  the  purpose  admirably  for  bone  work. 
A  useful  bone  drill  can  also  be  selected  from 
the  stock  of  the  hardware  dealer. 

A  gardener's  pruning  knife  and  a  cor- 
penter's  miter  saw  are  the  best  tools  for  the 
removal  of  plaster  dressings. 

A  cheap  potato  knife,   rough  sharpened 

99 


IN5TRUriENT5. 


on  a  stone,  is  excellent  for  cutting  through 
starch  bandages. 

Crochet  needles  are  most  useful  for  lifting 
buried  stitches  out  of  a  sinus. 

Knitting  needles  find  another  purpose  as 
a  means  of  rupturing  the  membranes  when 
this  is  needed  in  obstetrical  work. 

Sharp  and  blunt  retractors  may  be  fash- 
ioned, in  an  emergency,  by  bending  the  tines 
of  a  fork  and  the  handle  of  a  spoon,  respec- 
tively. 

A  teaspoon  is  also  useful  as  an  elevator  of 
the  eye,  when  resection  of  the  superior  max- 
illa is  performed. 

An  inverted  tea-strainer  is  useful  in  the 
dressing  after  colostomy,  to  prevent  pressure 
of  the  gauze  upon  the  gut. 

A  spoon-shaped  potato  cutter  may  be 
used,  in  an  emergency,  as  a  wound  curette. 

The  multiple  surgical  uses  of  the  hairpin 
are  also  well-known.     Of  stouter  material,  if 


lOO 


IN5TKUriENT5. 


necessary,  a  small  self-retaining  retractor  can 
be  quickly  made  from  steel  wire ;  it  often  ob- 
viates the  need  of  an  assistant  when  search- 
ing the  hand  or  foot  for  a  foreign  body. 

Similarly,  applicators,  probes  and  de- 
pressors may  be  improvised  by  twisting  stout 
copper  wire. 

A  wedge  of  hard  wood  makes  a  gag 
quite  useful,  often,  when  administering  anes- 
thesia. 

A  discarded  thermometer  case  (or  a  hard 
rubber  douche  point)  is  a  serviceable  handle 
in  which  to  mount,  with  candle  grease  or  ad- 
hesive plaster,  a  stick  of  silver  nitrate. 

A  bright  and  altogether  satisfactory  light 
for  throat  examinations  can  be  had  cheaply 
by  covering  a  1  6-candle-power  Edison  elec- 
tric bulb  with  a  smooth  layer  of  plaster-of- 
Paris,  about  three-eighths  of  an  inch  thick, 
leaving  on  one  side  an  aperture  the  size  of 
a  silver  half-dollar,  or  larger.  The  white 
inner  surface  of  the  plaster  brilliantly  re- 
flects the  light.  The  outer  surface  may  be 
painted  black  for  appearance's  sake. 


lOI 


lN5TRUriniNT5. 


Cheap  powder  blowers,  such  as  are  used 
for  insecticides,  may  be  employed  as  insuf- 
flators in  surgical  work,  and  pepper  boxes  are 
useful  for  dusting  powders. 

Steel  spring  tape-measures  are  better  than 
the  wires  generally  sold  for  the  purpose,  for 
conducting  to  an  x-ray  tube  the  current  from 
the  coil  or  static  machine;  easily  kept  taut, 
and  quickly  adjusted,  they  are  safest  for  the 
patient  and  most  convenient  for  the  operator; 
that  they  are  not  insulated  is  inconsequential 
— the  coverings  on  the  regular  wires  do  not 
insulate  the  induced  current. 

Wooden  skewers  are  serviceable  nail- 
cleaners.  Rolling  pins  and  kitchen  towel 
racks  are  very  convenient  for  adhesive  plaster, 
rubber  tissue,  etc.,  especially  for  hospital 
dressings. 

A  probe  that  has  become  bent  and  twisted 
is  readily  straightened  out  by  rolling  under 
the  foot  on  an  even  floor. 

The  threading  of  catgut  or  kangaroo  ten- 

oU  I  Uklo*      don   through   a   needle-eye   not   very   roomy 

may  be  made  easy  by  cutting  the  suture  end 


I02 


5UTURE5. 


obliquely  and  flattening  it  between  the  han- 
dles of  the  scissors.  Silk  must  not  be  cut 
obliquely,  however,  for  this  makes  it  apt 
to  ravel  while  it  is  being  threaded. 

Silkworm-gut  is  easily  dyed,  and  inciden- 
tally impregnated  with  an  antiseptic,  by  im- 
mersing it  for  twenty-four  hours  in  one  per 
cent,  solution  of  methyl  violet,  before  the 
boihng. 


When  suturing  a  wound  of  the  scrotum, 
if  the  tissue  (dartos)  is  contracted,  apply  a 
warm  compress  for  a  moment  to  cause  re- 
laxation. 

In  removing  a  skin  suture,  pull  up  on  one 
side  and  cut  it  as  close  to  the  skin  as  pos- 
sible. This  is  in  order  to  avoid  drawing 
any  of  the  exposed  part  of  the  suture  through 
the  wound  and  thus  possibly  infecting  it. 

Everything  is  to  be  gained  and  nothing  to 
be  lost  by  having  patients  remove  enough  of 
their  clothing  to  allow  of  a  completely  satis- 
factory examination  in  all  cases.  Instances 
can  be  called  to  mind,  by  any  physician,  of 
erroneous  judgments  arrived  at  before  ex- 
posure of  other  parts  of  the  body  showed  con- 


EAAniNA- 
TION5. 


103 


EAAnilNATIONS. 


ditions  altering  one's  opinion.  Especially 
is  it  important  to  compare  the  corresponding 
members  of  the  body  on  the  sound  and  the 
affected  side,  in  all  doubtful  cases. 

When  a  skiagraph  shows  a  condition  not 
recognizable  at  once  as  a  definite  lesion,  it  is 
important  to  make  an  x-ray  picture  of  the 
corresponding  part  of  the  body  on  the  other 
side.  It  may  show  that  the  condition  is 
merely  a  symmetrical  pecuharity,  and  not  a 
pathological  one. 

Before  excluding  glycosuria  examme  both 
morning  and  evening  specimens  of  the  urine. 

When  performing  an  office  operation,  too 
great  care  cannot  be  taken  to  sufficiently  roll 
back  or  remove  such  articles  of  clothing  as 
might  become  soiled.  The  patient  may  not 
say  much  if  he  is  obHged  to  draw  up  a  gar- 
ment wet  with  blood — but  he'll  probably 
think  a  few  things. 

Tar-paper  is  a  smooth,  fairly  waterproof 
material  to  tack  on  the  floor  when  preparing 
a  room  for  operation. 

DKE55INQ5.         Grocers'  paper  bags  are  well-adapted  re- 
ceptacles for  soiled  dressings. 

104 


DRE55IN05. 


When  a  "wet  dressing"  fails  to  properly 
drain  a  septic  wound  try  a  glycerin  dressing 
— gauze  wrung  out  in  pure  glycerin  and  cov- 
ered with  waterproof  material. 

When  wet  dressings  are  needed  on  hairy 
areas  it  should  not  be  forgotten  that  they 
predispose  the  hair  follicles  to  infection. 

Wet  dressings,  especially  the  very  useful 
Burow*s  solution  of  aluminum  acetate,  when 
applied  to  the  hand  or  foot,  usually  cause 
maceration  and  whitening  of  the  skin,  which 
is  apt  to  alarm  the  patient.  The  addition  to 
the  solution  of  one-fourth  its  bulk  of  glycerin 
or  alcohol,  will  obviate  this  unsightly  macera- 
tion. 

A  bichlorid  of  mercury  dressing  should 
never  be  applied  on  an  area  of  skin  on  which 
tincture  of  iodin  has  been  recently  painted. 
An  iodid  of  mercury  is  formed,  which  is 
highly  irritating. 

Ichthyol,  if  used  in  ointment  sufficiently 
strong  (25%  to  50%),  is  perhaps  the  most 
useful  single  medicament  in  aborting  early 
superficial  infections. 


105 


DRE55IN05. 


The  addition  of  a  little  oil  of  citronella 
to  an  ichthyol  ointment  robs  it  of  its  disa- 
greeable odor. 

A  2%  ointment  of  fuchsin  in  vaselin  or 
zinc  oxid  frequently  yields  gratifying  results 
in  stimulating  the  epidermization  of  indolent 
ulcers  and  granulating  wounds. 

Subiodid  of  bismuth  dusted  on  an  ooz- 
ing granulating  wound  promptly  stops  the 
bleeding.  It  is  also  an  excellent  stimulant 
to  the  growth  of  epithelium. 

An  ointment  of  beta-naphthol,  10;  sul- 
phur, 45 ;  lard,  24 ;  and  green  soap,  enough 
to  make  100  parts,  is  useful  in  removing 
gun-powder  not  too  deeply  situated  in  the 
skin.  It  must  be  employed  cautiously,  how- 
ever, to  avoid  a  destructive  dermatitis. 

Gauze  is  preferable  to  cotton  for  padding 
the  axilla  or  breasts  in  dressings  that  are  not 
frequently  renewed.  Cotton  easily  becomes 
matted  with  sour-smelling  secretions  and  thus 
sets  up  dermatitis.  The  skin  over  the  tendo 
Achilles  and  about  the  heel  cannot  be  too 
carefully  padded,  when  applying  Buck's  ex- 
tension apparatus. 


io6 


DKE55IN05. 


Collodion,  commonly  used  to  seal  a  punc- 
ture wound,  as  after  aspiration,  will  not  ad- 
here if  the  spot  is  wet  or  bleeding.  To  ob- 
viate this,  pinch  up  the  skin,  wipe  it  dry,  ap- 
ply the  collodion  and  continue  the  compres- 
sion a  minute  or  so  until  the  collodion  has 
begun  to  contract. 

When  rubber  tissue  is  not  at  hand  to  make 
a  "cigarette  drain,"  rubber  tubing  may  be 
used  in  its  place.  Split  a  piece  of  tubing  of 
appropriate  length,  and  lay  the  wick  of  gauze 
in  the  trough  thus  made,  or  draw  the  gauze 
through  the  tube  with  a  probe.  Fenestrae 
may  be  cut  as  desired. 

The  painfulness  of  withdrawing  packings 
that  have  dried  in  a  wound  may  be  avoided 
by  soaking  them  with  peroxid  of  hydrogen. 

A  urethral  endoscope  will  be  found  a 
great  help  as  a  means  of  introducing  a  rub- 
ber drainage  tube  into  a  narrow,  tortuous 
sinus. 

The  change  of  dressings  of  burns  may  be 
made  painless,  and  the  growth  of  epithelium 
encouraged,  by  employing  next  to  the  wound 
sterile  strips  of  gutta-percha  in  the  same  man- 


107 


DRE55IIN05. 


ner  as  for  skin-grafts.  Subiodid  of  bismuth 
lightly  dusted  on  the  granulating  surface 
stimulates  epithelial  growth. 

Patients  will  appreciate  the  use  of  black 
bandages  for  the  scalp — where  they  are 
comparatively  inconspicuous,  and  for  the 
hands — where  they  do  not  soil. 

Mastoid  and  scalp  dressing  may  be  re- 
duced in  bulk,  and  the  uncomfortable  neck 
turns  of  the  bandage  avoided,  by  the  use  of 
starch  bandages,  which  hold  neatly  and 
firmly. 

Bandages  may  be  fastened  m  place  more 
neatly  and  more  securely  with  strips  of  ad- 
hesive plaster,  than  with  safety  pins.  When 
bandaging  a  finger  or  toe,  turns  about  the 
hand  or  foot  will  be  unnecessary  if  the  dress- 
ing is  fastened  down  with  a  narrow  strip  of 
plaster  run  over  the  top  from  base  to  base, 
and  another  strip  circularly  about  the  dress- 
ing at  the  base  of  the  digit.  When  using 
black  bandages,  employ  black  adhesive 
plaster. 


io8 


INDEX 


PAGE 

Abdomen 

.     25 

Anesthesia 

90 

Appendix 

•     39 

Back             .          .         .          . 

61 

Bile  Tract 

.     30 

Bladder 

49 

Brain         .... 

.       8 

Breast            ... 

19 

Cranium 

•       7 

Dressings 

104 

Ear 

.       8 

Examinations 

103 

Extremities 

.     62 

Eye      .... 

10 

Face          .... 

12 

Foot    .... 

73 

Fractnres 

.     76 

Generative  Organs,  Female         .  .  58 

Genito-Urinary  Tract  .  -45 

Glands,  Lymphatic       ....         84 


ii  INDEX. — Continued. 

PAGE 

Hand 69 

Head 7 

Hemorrhage     ......  96 

Hernia            ......  40 

Infusions  ......     94 

Instruments  .....  97 

Intestines  .         .  .         -3^ 

Kidney 45 

Lymphatic  Glands  .         .         .         .         .84 

Mouth 13 

Neck 14 

Nose      .         .         .         .         .         .         .         II 

Penis 53 

Pharynx         ......         13 

Post-Operative  .  .         -95 

Prostate         ......         51 

Rectum     .......     41 

Scrotum         ......  55 

Sepsis       .......  97 

Shock 96 

Skin 84 

Stomach 32 

Sutures 102 


INDEX. — Continued.  iii 

PAGE 

Testicle 55 

Thorax 21 

Tracheotomy    ......  18 

Tuberculosis          .....  89 

Tumors 88 

Urethra 53 

Ureter 45 

Urinary  Tract        .....  45 

Wounds 85 


2002144743 


